Theories of Growth, Growth of Craniofacial structures

Dr. Shahistha Parveen

Assistant Professor
RAKCODS
 Learning Outcome

• Appraise upon the prenatal and postnatal growth and development of Maxilla,
mandible and cranio-facial structures with knowledge about the abnormalities
that can affect them
 Content
 Genetic Theory
 Sutural Theory
 Cartilaginous Theory
 Functional Matrix Theory
 Growth of Craniofacial structures
 Craniofacial disorders due to abnornmal growth
 Genetic Theory

Older concept

• Gene determines craniofacial growth

• Brodie (1940) noted the persistent pattern of facial configuration and assumed it
was under genetic control

• Genotype supplies all the information required for phenotypic expression

• He also said that it is possible to predict features of children from cephalometric data
of parents
 Genetic Theory
Newer concept/ Molecular Biology

• Dix genes, are critically important in development of the teeth and mandible

• Msx-1 predominates in tooth formation and is expressed in basal bone

• whereas Msx-2 is strongly expressed in the alveolar process

• Dix-1 and Dix-2 are expressed in the dental mesenchyme and in the epithelium of
the maxillary and mandibular arch mesenchyme, and other homeobox gene
groups have been shown to play a role in dental and facial development

• An association between a specific genotype for muscle proteins and

malocclusions (Class II and deep bite) has been demonstrated
 Sutural Theory

Bone is the primary determinant of skeletal growth

• SICHER believed that craniofacial growth occurs at sutures

• Accurate????

Evident:

• When the area of the sutures is transplanted to another location, the tissues does not
continue to grow

• If cranial or facial bones are mechanically pulled apart at the sutures, new bone will fill
in and the bones will become larger
• If a suture is compressed, growth at that site will be impeded

• Thus sutures must be considered areas that react—not primary determinants

• The sutures of the cranial vault, lateral cranial base, and maxilla are growth sites
but are not growth centers
 Cartilaginous theory- Cartilage determines bone growth

According the Scott

• Spheno-occipital synchondrosis -
responsible for the growth of cranial base

• Nasal sepal cartilage – responsible

for the growth of maxilla

• Condylar cartilage – responsible for the

growth of mandible
Cartilage determines bone growth!

A blow to one side of the mandible may fracture the

condylar process on the opposite side

When this happens, the pull of the lateral pterygoid muscle

distracts the condylar fragment, including all the cartilage, and
it subsequently resorbs
Cartilage determines bone growth

• Profile view of a man whose cartilaginous nasal

septum was removed at age 8, after an injury.

• The obvious midface deficiency developed after

the septum was removed.

• In early experiments, transplanting cartilage

from the nasal septum gave equivocal results—
sometimes it grew, sometimes it did not.
 Cartilage determines bone growth????

• Not totally accurate?

1. If cartilage is transplanted to another site it will produce bone

2. After condyle fractures, cartilage is lost the mandible can still grow

• It provides some control but not all the control

• Two studies carried out in Scandinavia demonstrated that after fracture of the
mandibular condyle in a child, there was an excellent chance that the condylar
process would regenerate to approximately its original size and a small chance that it
would overgrow after the injury..
 Summary

1. The epiphyseal cartilage, cranial base synchondroses, and the nasal

septum can act as growth center

2. Mandibular condyle growth is similar to the growth at the sutures of the

maxilla (entirely reactive) and considered to act as growth sites
 Functional Matrix Theory

This theory was developed by Melvin Moss in the 1960s and updated by him in the 1990s.

“ The growth of the face occurs as a response to functional needs and neurotrophic
influences and is mediated by the soft tissue in which the jaws are embedded. In this
conceptual view, the soft tissues grow, and both bone and cartilage react to this form of
epigenetic control”

It is based on Vaander Klaw’s “Form and Function theory”

Form≈ Function
 Functional Matrix Theory

Examples:

1. Growth of the cranial bone is a direct response to the growth of the brain.
Pressures exerted by the growing brain separates the cranial bones at the
sutures and new bone passively fills in at these sites
Cranial growth during microcephaly and hydrocephaly will depend on the size of the brain
and pressure in the head

1. When the brain is very small, the cranium is also very small, and the result is
microcephaly

2. second natural experiment is hydrocephaly. In this case, reabsorption of cerebrospinal

fluid is impeded, the fluid accumulates, and intracranial pressure builds up. The
increased intracranial pressure impedes development of the brain,
 Functional Matrix Theory

2. An enlarged eye or a small eye will cause a corresponding change in the size
of the orbital cavity. In this instance, the eye is the functional matrix.

• Moss theorized that the major determinant of growth of the maxilla and
mandible is the enlargement of the nasal and oral cavities, which grow in
response to functional needs
Functional Matrix Theory

• Hypotonic face, mouth breathers develop

maxillary deformity and crowding because no
tensile force is done by the lips
Functional Matrix Theory

Arch form and equilibrium

 Functional Matrix Theory

A severe infection of the mastoid air cells involved the temporomandibular joint and led to
ankylosis of the mandible. The resulting restriction of mandibular growth is apparent
 Development of Face

A A) Stomatodeum bounded by
B
frontonasal; (B) maxillary and
mandibular processes; (C) Formation
of nasal placodes with nasal pit
surrounded by lateral and medial
E
nasal processes; (D) Medial growth of
maxillary processes, pushing the left
and right medial nasal processes and
D C leading to their fusion; (E) Fusion of
various facial processes to form the
face
Growth of Palate

• Week 7: The palatal shelves grow vertically

lateral to the tongue
• Week 8: Tongue descends into the mandible and
palatal shelves are elevated
• Week 9-10: The palatal shelves proliferate and
fuse with each other and with the nasal septum
Cranial Vault

• The cranial vault is made up of flat formed by

intramembranous bone formation without
cartilaginous precursors

• Addition of new bone and growth occur at the

periosteum between

1. Adjacent skull bones

2. The cranial sutures

 Cranial Vault

• At birth, the flat bones of the skull are widely separated by loose connective tissues called
the fontanelle

• After birth, apposition of bone along the edges of the fontanelles eliminates these open
spaces, but the bones remain separated by a thin periosteum-lined suture for many years
eventually fusing in adult life
 Cranial Base

• Cranial Base is formed by endochondral ossification

• At 8 weeks, it appears as solid bar of cartilage extends from

the nasal capsule anteriorly to the occipital area posteriorly

• At 12 weeks, ossification centers appear in the midline

cartilage structures, and in addition intramembranous bone
formation of the jaws and brain case starts

• As ossification proceeds, bands of cartilage called

synchondroses remain between the centers of ossification
• The synchondrosis are between

1. Between two parts of the sphenoid bone (Intersphenoid synchondrosis)

close before birth.

2. Between the sphenoid and ethmoid bones (The spheno-ethmoidal

synchondrosis) closes around 6 years of age

3. The sphenoid and occipital bones (spheno-occipital synchondrosis) does

not ossify until 13–15 years of age. Thus, major growth occurs at spheno-
occipital synchondrosis, which would increase the anteroposterior dimension
of the skull base and may produce active growth up to the age of puberty
Prenatal Growth of Mandible

• In the mandible, bone formation begins

just lateral to Meckel’s cartilage and
spreads posteriorly along it without any
direct replacement of the cartilage by the
newly forming bone of the mandible
Meckel’s cartilage disintegrate except
some remnants which stay as
sphenomandibular ligaments
Prenatal Growth of Mandible

The condylar cartilage develops initially as

an independent secondary cartilage, which
is separated by a considerable gap from the
body of the mandible, and at 4 months, it
fuses with the developing ramus
Post natal Growth of Mandible

Both Endochondral and Periosteal activity are

important in growth of the mandible

• In the condylar cartilage: Endochondral

replacement

• Other areas of the mandible (ramus and body)

are formed by direct surface apposition and
remodeling) Intra membraneous growth
formation

Mandible grows downward and forward

Growth of Mandible- Post natal

• So, the body of the mandible grows longer by

periosteal apposition of bone on its posterior surface
of the ramus at the same time, large quantities of
bone are removed from the anterior surface of the
ramus

• While the ramus grows higher by endochondral

replacement of the condyle
Prenatal Growth of Maxilla - Nasomaxillary Complex

The maxilla forms initially as mesenchymal

condensation in the maxillary process, which is
located on the lateral surface of the nasal capsule
(intramembranous)

An accessory cartilage (Zygomatic or malar

cartilage), which forms in the developing malar
process, disappears and is totally replaced by

bone before birth (Endochondreal Ossification)

Post natal Growth of Maxilla (Nasomaxillary complex)

The maxilla develops postnatally entirely by

intramembranous ossification

The growth occurs in 2 ways:

1. By apposition of bone at the

sutures that connect the

maxilla to the cranium and

cranial base

2. By surface remodeling
Growth of Maxilla (Nasomaxillary complex)
Maxilla moves downward and forward relative to the
• cranium and cranial baseThis is accomplished by 2 ways:
1. By a push from behind created by cranial base growth
• Since the maxilla is attached to the anterior end of the cranial
base, lengthening of the cranial base, pushes it forward and
downward
• 2. By growth at the sutures
As the downward and forward movement occurs, the space
that would otherwise open up at the sutures is filled in by
proliferation of bone at these locations
Growth of Maxilla

• As the maxilla grow downward and forward, its

front surface is remodeled and bone is removed
from the anterior surface (Except from the anterior
nasal spine)

• The anterior part of the alveolar process is a

resorptive area, so removal of bone from the
surface tends to cancel some of the forward
growth that otherwise could occur because of
translation of the entire maxilla
 Facial soft tissues growth
Growth of the Lips Growth of the Nose
Height:
• Bone growth is complete by age 10
• Short during mixed dentition
• Maximum during childhood • Cartilage and soft tissue grow during
• Decreases from late adolescence adolescence

Thickness
• Maximum during Adolescence
• Decreases gradually afterwards
Growth of lips- Height

• Growth of the lips trails behind growth of the

facial skeleton until puberty, then catches up
and tends to exceed skeletal growth
thereafter

• As a result, lip separation and exposure of the

maxillary incisors is maximal prior adolescence,
and decreases during adolescence and early
adulthood
Growth of lips- Thickness

• Lip thickness increases during the

adolescent growth spurt, then
decreases (and therefore is maximal at
early ages)

• For some girls, loss of lip thickness is

perceived as a problem by their early 20’s
Growth of the nose

• The nasal bone grows until about age 10, after age
10, growth of the nose is largely in the
cartilaginous and soft tissue portions

• Especially in boys, the nose becomes much more

prominent as growth continues after the
adolescent growth spurt (and this process
continues into the adult years)
 Craniofacial Deformaties

1. Hemifacial microsomia/ Goldenhar Syndrome

2. Pierre Robin Sequence

3. Treacher Collins Syndrome

4. Craniosynostosis
1. Crouzon Syndrome

2. Apert Syndrome

5. Down Syndrome

6. Cleft lip and palate

Hemifacial microsomia/ Goldenhar Syndrome

• Small half of the face

• Ipsilateral (same side) external ear deformity

• Central nervous system and vertebral anomalies

Occasional heart anomalies

 Pierre Robin Syndrome

A fetus’ head is flexed tightly against the chest, preventing the

mandible from growing normally resulting in small mandible
at birth, usually accompanied by a cleft palate (The restriction
on displacement of the mandible forces the tongue upward and
prevents normal closure of the palatal shelves). This extreme
mandibular deficiency is termed the Pierre Robin sequence

Triad consisting of
1. Mandibular hypoplasia
2. Cleft palate
3. Glossoptosis (Downward placement of the tongue)
Pierre Robin Syndrome
Treacher Collins syndrome (Mandibulofacial Dysostosis)

1. Downward slanting of the eyes

2. Eyelid coloboma

3. Mandibular hypoplasia

4. Microtia (ears)

5. Macrostomia (mouth)

6. Hypoplastic zygomatic arches

7. Occasional cleft palate

 Craniosynostosis

• Congenital anomaly characterized by premature fusion of

the cranial sutures

• Caused by a variety of mutations involving fibroblast growth

factor receptor genes

• It can affect the cranial base and facial sutures causing severe
midface retrusion

• Surgical release of the prematurely fused areas is needed

to maintain normal head shape and facial proportion

• The ideal time for surgery to release fused cranial sutures is

between 6 and 9 months of age
1. Apert Syndrome

1. Midface hypoplasia

2. Syndactily of the hands and feet

3. Cleft palate

4. Varying degrees of mental retardation

2. Crouzon Syndrome
• This syndrome arises because of prenatal fusion of
the superior and posterior sutures of the maxilla
along the wall of the orbit.

Characterized by

1. Hypertelorism: an abnormally large distance

between the eyes

2. Exophtalmos: the protrusion of one eye or both

3. Parrot beaked nose

4. Maxillary hypoplasia

5. Occasional hydrocephalus
Down Syndrome

Down syndrome is a condition in which a child is born

with an extra copy of their 21st chromosome

Characterized by
1. Mental retardation
2. Heart disease
3. Hypotonic face
4. Macroglosia
5. Skeletal class III
6. Oral breathing (caries)
7. Tooth size anomalies
Cleft Lip and/or Palate

Cleft of lip and the palate is one of the most

common congenital anomalies resulting from
failure fusion of Maxillary processes with palatine
processes
Etiology:
1. Various sporadic gene mutations
2. Environmental factors
3. Maternal smoking
4. Teratogenic drugs
5. (Vit. A) deficiency
6. Radiation
Median Mandibular Cleft
• First branchial arch fails to fuse resulting in cleft
between
1. Lip
2. Mandible
3. Hyoid bone
4. Tongue
Mandibular Prognathism

• Autosomal dominant inheritance

• Mandibular prognathism in the Hapsburg

family became known as the Hapsburg
jaw because it recurred over multiple
generations in European royalty and was
recorded in many portraits
Thank you