Postnatal Growth of the Craniofacial Complex :

PART I
 CONTENTS

Introduction Controlling factors of growth

Factors affecting growth

Definition
Methods for studying growth
Osteogenesis- Types of ossification
Theories of growth
Growth Pattern, Variability and Timing
Conclusion

Distance and Velocity curve References

 LEARNING OBJECTIVES

At the end of this seminar the listener should be able to answer-

• Types of ossification
• Growth Pattern, Variability and timing
• Controlling factors of growth
• Theories of growth
 GROWTH

Stewart (1982)
• Growth is a process that leads to increase in physical size of cells,
tissues, organs or organisms as a whole

Profitt (1986)
• Growth refers to increase in size or number

Moyer (1988)
• Growth may be defined as the normal changes in the amount of
living substance
5
 Stedman (1990)

• Growth is an increase in the size of a living being or any of its parts,

occurring in the process of development.

Pinkham (1994)

• Growth signifies an increase , expansion or extension of any given

tissue.

6
 DEVELOPMENT

▰ The naturally occurring unidirectional 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 can be consider as a continuum of casually related events from the

fertilization of ovum onwards.
- Moss
Growth Differentiation Translocation Development
Differentiation

• Change from generalized cells to more specialized kind

Translocation

• Change in position

Maturation

• Qualitative changes which occur with ripening or aging.

 FORMATION OF BONE

Craniofacial skeleton is derived from two unique processes:

• Endochondral bone formation

• Intramembranous bone formation
 Endochondral bone formation

Chondrocytes(cartilage cells) differentiate from the

original mesenchymal cells
Form a rough model- enclosed by perichondrial
cells of the future bone.
Cartilage mass grows rapidly, both by interstitial and
appositional increments.

A primary bone-forming center becomes apparent.

Mature cartilage cells hypertrophy

 Simultaneously from the perichondrium there is a proliferation of blood
vessels into the changing cartilage mass.

These proliferating vessels carry with them undifferentiated mesenchymal

cells, which eventually form osteoblasts.

The new osteoblasts deposit bone on the surface of the degenerating

calcified cartilage matrix, forming bone spicules
 Membranous bone formation

The osteoblasts arise from a concentration of undifferentiated mesenchymal cells.

Osteoid matrix is formed by the newly differentiated osteoblasts and then calcifies
to form bone.

As the osteoblasts continue to form osteoid, they become ‘entrapped’ in their own
matrix and become osteocytes.
The blood vessels that originally nourished the undifferentiated mesenchyme
found passing through the remaining connective tissue.

Interlaced between the bony trabeculae.

The final bone’s vascularity depends on the speed with which it was formed.

The faster the bone forms, the more vascular channels one will see.
 GROWTH PATTERN

Pattern :-

• The way in which various parts of body are arranged in a proportional relationship.
• Set of constraints operating to preserve the integration of parts under varying
conditions or throughout life. (Moyers)
 CEPHALOCAUDAL GRADIENT OF GROWTH

It is a change in the body proportions that occurs in normal growth & development.

A) 3rd month of intrauterine life

• Head :- 50% of the total body length.

• Cranium:- Large relative to face and represents
more than half of the total head.
• Limbs:- Underdeveloped.
B) At time of birth
• Portion of head – decreases to 30% of total body length.
• Trunk & Limbs – Grows faster than head & face.(leg is 1/3 rd of total
body length)

C) Adult

• Progressive reduction in size of face – 12% total head body length.

• Portion of head reduce from birth to adult
• Legs- ½ of total body length
Increased axis of growth in the caudal
direction is called cephalocaudal growth
gradient.

At birth – Jaw and Face less developed

compare to skull.

Growth of mandible completes later than

maxilla.
 SCAMMON’S GROWTH GRADIENT
(Richard Scammon)

Reduce the growth curves of tissue of the body to 4 basic curves.

Lymphoid

Neural

Somatic (General)

Genital
Lymphoid Curve

• Includes Thymus, Pharyngeal and

tonsillar adenoids, lymph nodes and
intestinal lymphatic masses.
• Rises to high point of 200% - 10 -15 years
of age.
• After that it reduces from 200% to 100%.
Neural Curve
• Includes brain, spinal cord, optic apparatus
& related bony parts of the skull and upper
face & vertebral column.
• Curves rises strongly during childhood.
• At 8 years – Brain is nearly 95% of adult
size.
• 8 year old child function mentally at nearly
the same level as an adult.
General curve

• Includes external dimensions of body,

respiratory and digestive organs, kidney,
aorta and pulmonary trunks, spleen,
musculature, skeleton and blood volume.
Genital curve

• Small upturn in the 1st year of life

• Quiescent until 10 year of age
• Increase during the time of puberty
Clinical Significance Of Scammon’s Growth Curve

• Maxilla follows neural growth pattern and it’s growth ceases earlier in
life.
• Skeletal problems of the maxilla should be treated earlier than that of
the mandible.
• Mandibular growth follows general growth pattern. It grows upto 18-
20 years.
 GROWTH SPURTS

Period during which growth processes are turned on.

Alterations in hormones – accentuate growth.

Timing differs:-

• Boys
• Girls
Timing of growth spurts:-

• A) Just before birth

• B) One year after birth
 • Boys: 8-11 years
Mixed dentition
• Girls: 7-9 years

• Boys: 14-16years
Pre-Pubertal
• Girls: 11-13 years

• Boys: Till 25years

Pubertal
• Girls: 18-20years
 Clinical Significance of the Growth Spurts:

To identify growth changes are normal or pathologic.

Treatment of skeletal discrepancies

Pubertal growth spurt offers the best time of majority of cases in terms of
predictability, treatment direction, management and treatment time.
Orthognathic surgery should be carried out after growth ceases.

Arch expansion is carried out during the maximum growth period.

 VARIABILITY

Variability is law of nature

No two individual grow in same manner.

• Deviation from the usual pattern.

• Express in the quantitative manner.
• Can be done with the help of growth chart, where child is evaluated to their
peers on a standard growth chart.
Growth charts commonly used are

• Height & weight for age

• Head circumference for age
• BMI for age
• Weight for stature.

The chart has solid lines on the graph which

depicts how far an individual varies from the
usual pattern.
Velocity and Distance curve

Distance curve

• Rapid growth upto 2 years

• Steady increase in height upto 13 years
• Acceleration due to pubertal growth
spurt
• Slow down until adulthood
 SITE VS CENTER

Growth Site –

• Merely a location at which growth occurs.

Growth Center –

• Location at which independent or genetically controlled growth occurs.

All growth centers are also growth sites, whereas all growth sites are not
Profitt -
centers.
 Growth Site Growth Center/Growth Field

1. Is a region of periosteal or sutural bone formation 1. Are places of ossification with tissue separating
and force
remodeling resorption adaptive to environment
2. Sites of growth when transplanted to another area, 2. Centers of growth when transplanted to another
does not continue to grow area, continues to grow
3. Marked response to external influences 3. Less response to external influence. More response
to functional needs
4. They do not cause growth of the whole bone, instead 4. Cause growth of the major part of the bone
they are simply places where exaggerated growth takes
place
5. All growth sites are not growth centers 5. All growth centers are growth sites

6. Theories of growth are not based on growth site 6. Various theories of growth are based on the place
where growth center is expressed
7. Growth sites do not control the overall growth of the 7. Growth center controls the overall growth of the
bone bone
 Controlling Factors In Craniofacial Growth

Von Limborgh’s Goose and Applenton’s

Intrinsic genetic factor Endocranial factors
Local genetic factor Multifactorial inheritance
General epigenetic factor Racial differences
Local environmental factor Nutrition
General environmental Diseases
factor
Socioeconomic factors
Secular trends
 Factors Affecting Growth

Nutrition

• Malnutrition affect –
• Size of parts, body proportions, quality and texture of tissues and
onset of growth events.
• If adverse effect are not to severe, the growth process accelerates when
proper nutrition is provided- catch-up growth.
Illness-

• Prolonged and debilitating illness however can have a marked effect

on all aspects of growth.

Race-

• Differences in growth among various races. e.g American blacks,

calcification and eruption of teeth occur almost a year earlier than their
white counterparts. Asians are generally shorter than Europeans.
Socio-economic factors-

• Children brought up in affluent and favorable socio-economic

conditions show earlier onset of growth events.

Family size and birth order-

• 1st born babies tend to weight less at birth and have smaller
stature but higher IQ. The small family size – better nutrition.
Psychological disturbances -

• Children experiencing stressful conditions display an inhibition of

growth hormone secretion.

Exercise-

• Influences development of motor skills and increase in muscle

mass
METHODS OF STUDYING GROWTH
Profitt
Measurement approaches

- Carried on living individuals and do not harm the animal.

• Craniometry
• Anthropometry
• Cephalometry
• Arcial growth
• Logarithmic spiral
•
Experimental approaches

- Destructive technique where animal that is studied is sacrificed.

• Vital staining
• Radioactive tracer
• Autoradiography
• Implant radiography
 VITAL STAINING

Vital staining is an experimental method of measuring growth.

Introduced by John Hunter in the 18th Century.

Belchier (1936) –

• Alizarian dye from maddler plant was identified and used for bone
research.
Dye administered in the experimental animal –

• Manner in which bone laid down, site of growth, the direction, duration
and amount of growth at different sites in the bone.

Dyes used are

• Alizarian red 5
• Acid Alizarian
• Trypton Blue
• Tetracycline
• Lead acetate
 RADIOISOTOPES

Elements when injected into tissue get incorporated in developing bone.

Detected by tracing down the radioactivity they emit.

Commonly used –

• Technetium - 33
• Calcium- 45
• Potassium- 32
 IMPLANTS

Bjork -1969

Implanting small bits of biologically inert alloys into the growing bone.

Tantalum metal –

• Length – 1.5mm
• Diameter -0.5mm.

Embedded in certain areas of maxilla and mandible - to study growth of skull.

 MAXILLA

1. Hard palate behind the deciduous canines (prior to

eruption of maxillary permanent incisors)

2. Below the anterior nasal spine (after eruption of

maxillary incisors)
3. Two Implants on either side of Zygomatic
process of maxilla.

4. Border between hard palate and alveolar

process medial to the first molar
MANDIBLE

1. Anterior aspect of symphysis, in the midline below the

root tips.

2. Two pins on the right side of mandibular body.

3. One pin under the 1st premolar and other below the 2nd
premolar or 1st molar.

4. One pin on the external aspect of right ramus at the

level of occlusal surface of molars.
 RADIOGRAPHIC
TECHNIQUES

Commonly used-

A. Cephalometry

• Broadbent- 1931
• For craniofacial region
• Study the growth changes
 Hand wrist radiograph

• Biologic and skeletal age of a person

• Carpels- definite schedule of appearance
and ossification.
 MECHANISM OF BONE GROWTH
Enlow (1963)

MECHANISM OF GROWTH

DRIFT - DISPLACEMENT -

Direct bone growth by means of Occurs due to growth of bone itself or

deposition and resorption processes on expansion of adjacent structures.
the bone surfaces.
 DRIFT

The bony cortical plate drifts by depositing and resorbing

bone substance on outer and inner surfaces respectively.

If deposition and resorption take place at a same rate, the

thickness of the bone remain constant.
 (A) Cortical plate of Bone

(B) Increase in thickness due to apposition on one of the surfaces

(C) When the resorption process on one side of the bone exceeds the apposition
process on the opposing side, the thickness of the bone will be reduced

(D) When resorption on one side of the bone corresponds in magnitude to

apposition on the opposing side, the bone will drift without changing its size

(E) The cortical plate has drifted completely to the right when compared to its
original position in ‘A’ by the process of remodeling
DISPLACEMENT

Movement of whole bone as a unit.

The entire bone is carried away from its

articular interfaces with adjacent bones.
 PRIMARY DISPLACEMENT

As a bone enlarges it is simultaneously carried away from the other bones in

direct contact with it.

This creates space within which bony enlargement takes place.

Physical movement of whole bone, as bone grows and remodels by

resorption and apposition.
 SECONDARY DISPLACEMENT

Movement of whole caused by the separate enlargement of other bones,

which may be nearby or quite distant.

Movement of bone related to enlargement of other bones.

 THEORIES OF CRANIOFACIAL GROWTH

Bone remodeling Cartilagenous

Genetic theory Sutural theory
theory theory

Functional Servo system

Neurotrophism
matrix theory theory
 Bone Remodeling Theory:

Brash (1930) states “ bone grows only by interstitial tissue”.

3 fundamental tenets:

• Bone grows only by apposition at the surface.

• Growth of jaws takes place by deposition of bone at the posterior
surfaces of maxilla and mandible –Hunterian growth.
• Calvarium grows through bone deposition on the ectocranial surface of
cranial vault and resorption of bone on endocranial surface.
GENETIC A. Brodie (1941) stated – “ Genes determine and control whole
THEORY: process of craniofacial growth”.

Gregor Mendel opened up field of genetics, regarding mech. of

inheritance and transmission.

Two principle “ Transmission genetics” – explained methods of transmission

areas : based on Mendelian laws (genes). It could not explain all the changes
taking place in craniofacial growth.

“Molecular genetics” – undergoing profound development and

discoveries.
 Sutural hypothesis / Sutural dominance theory:
(Sicher and Weinnman 1952)

Sutures, cartilage and periosteum-

Facial growth were assumed to be under intrinsic genetic control.

Essence of theory-

Craniofacial skeleton enlarges due to

Sutures are primary determinants of
expansible forces exerted by sutures
craniofacial growth.
as they separate.
▰ “Sutural dominance theory” because – primary event in sutural growth is
proliferation of C.T between two bones.
▰ Cranial vault
▰ Growth of midface
Evidences against the theory:

• Trabecular pattern in bones - Change with age, indicating changes in direction

of growth, it cannot be accepted that sutures will have any information
regarding altering growth.
• Extirpation of facial sutures – no appreciable effect on dimentional growth of
skeleton (Sarnat, 1963)
• Growth at sutures is in lateral direction, so it is impossible for sutures running
in same direction to push maxilla parallel to reference plane.
 Conclusion:

Sutures as adaptive growth sites.

Sutural tissues have no tissue separating forces and are not comparable
to growth centers
 CARTILAGINOUS THEORY
Scott Hypothesis/ Nasal Septum Theory/ Nasocapsular Theory

Nasal septum is mostly active and vital for

craniofacial growth late prenatally and early
postnatally.

Anteroinferior growth of nasal septal cartilage, which

is buttressed against cranial base – “pushes” the
midface downward and forward.
Controlling Factors Of Growth As Per Scott:

Anatomic location
Chondrocranial growth Desmocranium

Controlling factors

Intrinsic genetic Local

Local epigenetic
factors environmental
Discussion

According to Scott – Two suture systems

• Posterior suture system – Lies behind maxilla and

separates it from palatine, lateral mass of
ethmoid, lacrimal, zygomatic and vomer bones.
• Anterior suture system separates premaxilla, nasal
and vomer bone.
 Evidences supporting the theory:

 Extirpation of septal cartilage in growing rats resulted in deficient growth of snout

(Sarnat, 1966)
 Nasal septum has a role in determining anteroposterior growth of upper face
(Latham and Burstone, 1966)
 Steinler, Kvinslaw compared increase in size of autotransplanted nasal septum in
subcutaneous abdominal wall in rats suggesting nasal septum has intrinsic growth
potential.
 Evidence against the theory:

Septal cartilage provides only mechanical support for nasal bones and is not primary
growth center. (Moss and Bloonberg ,1968 ; Thilander,1970)

Downward sliding of vomer in relation to anterosuperior part of nasal septum takes

place throughout craniofacial development making it unlikely that cartilaginous
septum could push maxillary complex forward. (Melson 1977)
Malformation in snout following excision of nasal septum is due to
trauma following surgery. (Moss)

A child with missing nasal septum had normal resorption and

deposition of palate, height of upper face. Sagittal development was
affected. ( Burstone and Latham)
 Conclusion:

Nasal septum theory – still accepted for craniofacial growth.

Nasal septum – anteroposterior growth of face because of endochondral growth

process occuring at its posterior border.

Not an active contributor for vertical development of face.

 FUNCTIONAL MATRIX THEORY
(Melvin Moss, 1960)

Essence of the theory:

• Except from initiating process of development, heredity and genes play no

active role in growth of skeletal structures.
Bones do not grow, bones are grown.

• States that expansion of soft tissue matrix is primary and bone growth is
purely a secondary and compensatory event.
• Translation of various bones is due to volumetric expansion of encapsulated
spaces or tissues.
Controlling influences on growth according to Moss
 Definition

Functional Matrix Hypothesis claims that:

• The origin, form, position, growth and maintenance of all skeletal tissues and
organs are always secondary, compensatory and obligatory responses to
temporarily and operationally prior events or processes that occur in specifically
related non-skeletal tissues, organs or functioning spaces.
Together the soft tissues & skeleton elements related to a single function are termed as
“Functional cranial component”.

Functional cranial
component

Functional matrix Skeletal unit

Periosteal Capsular Microskeletal Macroskeletal

matrix matrix unit unit
 FUNCTIONAL MATRIX:

▰ Refers to all soft tissues and spaces that perform a given function.

Periosteal matrix:

• Corresponds to immediate local environment

• Muscles, blood vessels, nerves
• Act by deposition and resorption
• Its stimulation causes growth of microskeletal unit.
• Act to alter size or shape or both of the bones.
• Growth process- transformation
Capsular matrix:

• Envelope which contains series of functional cranial components,

which as a whole are sandwiched between two covering layers.
• Functional cranial component→ skeletal unit + functional matrix.
• Cranial capsule → several functional cranial components
• Neurocranial capsule- skin & duramater.
• Orofacial capsule- skin & mucosa.
• Growth process- translation
 SKELETAL UNIT:

▰ Refers to bony structures that support functional matrix and these are necessary or
permissive for that function.

Microskeletal unit

• Parts of bone whose growth is modulated by periosteal matrices.

• Periosteal matrix and microskeleton interaction
• Temporalis muscle - Coronoid process
• Masseter, medial pterygoid- Angle of mandible
• Teeth- Alveolar bone
• Transformation
Macroskeletal unit

• Made of core of maxilla, mandible and neurocranium.

• Basic maxillary unit – supports & protects infraorbital
neurovascular triad.
• Mandible – basal tubular portion which protects mandibular
canal.
• Translation
Capsular matrix and macroskeleton interaction :

• Nasal mass- Cranium

• Eye mass- Orbit
• Orofacial capsule- Core of mandible and maxilla
FUNCTIONAL CRANIAL ANALYSIS OF MAXILLA

No such entity as maxilla, from functional point of view.

Basal bone – Designates maxillary skeletal unit which serves to protect and
support infraorbital neurovascular triad.

Max. division of trigeminal nerve – Maintains spatial constancy of infraorbital

canal to anterior cranial base.
Infraorbital foramen – First ossification site of maxillary bone.

Orbital mass functional matrix – Ceases growth by end of 1st decade.

All maxillary functional matrices – Come to rest.

Nonbasal maxillary matrices – Continue to grow after 10yrs of life.

FUNCTIONAL CRANIAL ANALYSIS OF MANDIBLE:

Mandibular matrix consists of –

• All muscles with mandibular attachments

• Neurovascular triads
• Associated salivary glands
• Teeth
• Fat, skin, connective tissue
• Tongue
• Oral and pharyngeal spaces.
 Conclusion

Both genomic and epigenetic factors are necessary.

Together both provide the necessary and sufficient cause for the control
of morphogenesis.
 Neurotropism

Neurotropism “is a non-impulse transmittive neurofunction, involving

axoplasmic transport, providing for the longterm interactions between
neurons and innervated tissues which homeostatically regulate the
morphological, compositional and functional integrity of those tissues”.
The nature of neurotropic substances and the process of their introduction
into the target tissue are unknown at present.

Moss does indicate that there are three general categories:

• Neuroepithelial
• Neurovisceral
• Neuromuscular.
 SERVO SYSTEM THEORY

Alexander Petrovic,1977

According to theory -

• Primary cartilages – controlled by cybernetic form of “command”

• Secondary cartilages – direct effect of cell multiplication.
• Cybernetics – Science of control and communication in animal and machine.
(Weiner)
Cybernetic theory –

“ The behaving organism is not seen as a passive respondent called

into action by changing environment stimuli but as a dynamic
system which continuously generates intrinsic activity for
organized action with the environment.”
Approach to servo system concept
Servo system theory of craniofacial growth, with emphasis on the growth of
the mandible.
Evidences against the theory:

• Resection of lateral pterygoid fails to diminish condylar growth.

(Awn,1983)
• In a bilateral condylectomy model, no difference was found in growth
with direct muscle traction and lateral pterygoid removal.
(Johnson,1985)
• Occlusion remained unaffected in condylectomy sites. (Das, Myer and
Sicher,1980)
Conclusion:

• Condylar growth can be modified therapeutically or in response to

functional requirements.
• Provides a road map for future research and experimentation.
• Applications - explains mode of action of functional appliances.
 V Principle

Important Facial skeleton growth mechanism.

Inner side – Bone deposition

External surface – Bone resorption

The ‘V’ Moves away from its tip and enlarges

simultaneously.
• Movement of bone towards the broad end of the
‘V’

• The ‘V’ moves away from its tip and enlarges

simultaneously.

• Thus, an increase in size and growth movement

takes place in a unified process.
• Hence, it is also called the expanding ‘V’
principle.
 Enlow’s counterpart principle

The vertical and horizontal size of a given part is compared with its specific
counterparts.

The growth activity in one region is invariably accompanied by complementary

growth in other regions.

Essential for maintaining functional and esthetic balance.

DIFFERENT COUNTERPARTS OR GROWTH EQUIVALENTS

Nasomaxillary complex elongation is the counter part for elongation of

anterior cranial fossa.

Lengthening of spheno-occipital region is the growth equivalent of underlying

pharyngeal region and increasing length of ramus.

Combined vertical lengthening of the clivus and mandibular ramus is the

growth equivalent of total vertical nasomaxillary region.

Maxilla and mandible are mutual counterparts.

 Conclusion

It is important for the clinician to know the normal and the abnormal ranges of
growth for proper diagnosis, treatment planning and selecting appropriate
clinical procedures.

We can get a better understanding of the deviations from the normal that
occurs during growth.
 REFERENCES

• Sridhar Premkumar’s textbook of craniofacial growth

• Bhalajhi orthodontics – the art and science 5th edition.
• Proffit’s contemporary orthodontics 4th edition
• Graber’s textbook of orthodontics 4th edition
 QUESTION ASKED IN PREVIOUS EXAMS

▰ 1. Describe growth and development under the following heading:

▰ i) Define growth and development
▰ ii) describe theories of growth
▰ iii) categorize and explain the growth assessment parameters used in
children. (LAQ- DMIMS 2012)

2. Functional matrix theory. (SAQ- DMIMS 2015)

Thank You