Craniofacial growth

Cranio Facial
Growth Process
www.indiandentalacademy.com

INTRODUCTION
Every orthodontist should keep in mind
that the patient on whom he/she
works are in the state of growth and
development, which is a dynamic and
continuously changing process.
He/she almost never find a static
picture in an orthodontic patient
unless it’s a adult patient.www.indiandentalacademy.com

So a thorough understanding of
complex craniofacial growth is of
great importance for us.
Understanding of developing
craniofacial skeleton represents,
sum of growth of its separate parts
in which growth is highly
differentiated and occurs in and at
different rates, dimensions and time.

Growth and development can be seen
in three aspects
a) Change in dimension
b) Change in proportion
c) Maturation

DEFINITION OF GROWTH
STEWERT (1982): Growth is increase in
mass and physical size of cell, tissues,
organ, or organisms as a whole.
PROFFIT (1986): Growth refers to increase
in size or number.
MOYERS (1988) :Growth is normal change
in the amount of living substance.
PINKHAM (1994) :Growth is increase
expansion or extension of any given
tissue. www.indiandentalacademy.com

DEFINITION OF
DEVELOPMENT
TODD(1931) :Development is increase
in complexity.
LOWREY(1951) : Development
indicates increase in skill and
complexity of function.

DEFINATION OF
DEVELOPMENT
MOYER(1988) :Development is the
unidirectional change in the life of an
individual from its existence as a single
cell to terminating in depth .
PINKHAM(1994) :Development addresses
the progressive evolution of a tissue.

DIFFERENTIATION :The change from a
generalized cell to one that is more
specialized .It is change in quality and
kind .
growth and development are used
synonymously, but they are not.

Growth is increase in size or number of
things .It is numerical .can be easily
measured with a specified scale.
Ex. Height , weight of persons.
*Development is increase in skill and
complexity of function.
But, practically growth and development
are inseparable entities and are
simultaneous on going process which
go hand in hand

• THEORIES OF GROWTH

GENETIC GROWTH
(Brodie)
• It says, growth is cantrolled by
genetic influence in all aspect. But it
cannot be accepted in all cases. As it
has been shown that the external
factor have significant modifying
effect on growth
•

SUTURAL THEORY
(sicher)
• It says that the proliferation of sutural
mesanchyme causes apposition of bone .
It is seen in membranous bone.
• Limitation :- lack of growth of suture if it
is transplanted .
• gowth occurs in cleft lip and cleft palate
pts.even if suture not present
• Suture also respond to external influence
•

CARTILAGENOUS THEORY
(James Scott) :
• It says that cartilage acts as primary
growth center and has a innate growth
potential
• Ex ; condylar cartilage for mandible
• Nasal cartilage for maxilla
(nasomaxillary complex)
• If it is transplanted it grows
independently

FUNCTIONAL MATRIX THEORY
(Melvin Moss –1968)
• It says that body has two element
• a) skeletal element
b) functional matrix
• functional matrix comprised of
• 1)periosteal camponent
• 2)capsural camponent
• (neuro cranial),(orofacial)
• functional matrix has primary control on
growth of skeletal unit and bone respond
in passive manner
• but it can not explain all
aspects of growth

MULTY FACTORIAL THEORY
(Van Limborgh)
• It says bone growth is controlled by
• a) intrinsic genetic factor
• b) local epigenetic factor (nerves,
brain )
– C)general epigenetic factor (harmones,
secondary messengers )
– d) local environmental factor (habit,
muscular force )
– e) general environmental factor (
oxygen, nitrogen)
• It is most satisfactory theory that
explains all aspect
• It says growth is polygenic

NEUROTROPISM
(recent theory )
• It includes epithelial , visceral , muscular
component for these component nerve
impulses which are transmitted has
growth potential for bone .It also has
indirect effect by influencing soft tissue
growth
• but by experiments it has proved that
neurotropism has negligible effec

PETROVICS HYPOTHESIS
• It says that the interaction of
serves of casual changes and
feedback mechanism which
determines craniofacial growth
• ie brain---- cranium.

• THEORIES RELATED TO
CRANIOFACIAL
GROWTH
•

ENLOWS EXPANDING “V”
PRINCPLE
• It says that most of craniofacial bones
especially intramembranous have v
shape eg:maxilla , mandible , palate
,nasal etc.
• And growth movement occurs
towards wide end of V deposition of
bone is seen in inner side and
resorption is seen in outer surface.

ENLOWS COUNTERPART
PRINCIPLE
• It explains that, growth of one bone
has influence on its adjuvant bone
which is called counter part, and
this controls the growth and
proportional relationship with its
counterpart.
• E.g.:- nasomaxillary complex—
cranialfossa
• Maxilla ----------mandible
• Tuberosity areas of upper/lower
jaw Pharyngeal space -----

FACTORS AFFECTING
PHYSICAL GROWTH
• Heredity
• Nutrition
• Illness
• Race
• Socioeconomic states
• Family size
• Psychogenic disturbance
• Exercise
• Pharmacological

characteristic properties
of growth
• concept of normality
• growth states are
always accessed in normality value
ie. in range but can not be explained
as ideal with a definite value
• Normality differs from age to
age

• Different growth :
• Different organs grow
at different rate , different amount,
and different time .
• It can be best
explained by SCAMMONS GROWTH
CURVE

• CEPHALOCUADAL GRADIENT OF
GROWTH
• Axis of growth increases
extending from head to feet
• ie. 3 months intra uterine life head size---
50%, birth head size---30%, adult head
size---12% of whole body
•
• Cranial growth 70% completed at birth to
1st year
• limbs 3month IUL-1% by birth-50% of
body

GROWTH SPURTS
• Despite growth being a continuous process,
there occurs a period when a sudden
acceleration of growth occurs called growth
spurts.
• It is due to physiological alteration in hormonal
secretion.
• They differ in boys and girls.
• This period is good for functional and orthodontic
appliance use.
• Surgical correction involving jaws should be
carried out after cessation of growth spurts .

Timings of growth spurts
A) just before birth
B) one year after birth
C) mixed dentition
girl—7-9yrs
boys- 8-11yrs
D) pre pubertal
girls ----11-13 yrs
boys -----14-16yrswww.indiandentalacademy.com

METHODS OF STUDING
GROWTH
a) measurement approach
bimanual test height and weight
b) experiment al approach :-
vital staining- alzirine blue
alzirine red
lead acetate
Radioisotopes- te 33, Ca*45,
K*32 injected in bone
c) implants
d) radiographs.

Mechanism of bone
development
• 1)endochondral bone
• 2)intramemebranes
• endochondral bone this type of bone is
proceded by formation of cartilaginous
model
• intramembranes bone – bone is directly
laiddown in fibrous membrane

Prenatal growth
{day1 to 266 day}
It is divided into 3 periods
1) period of ovum (ferti. to 14th day)
2) period of embryo (14th day to 56th day)
3) period of fetus (56th day to birth)

PERIOD OF OVUM(fertilization to 14th
day)
• In this period, oocyte get fertilized with
spermatozoa to form zygote which is a
diploid cell. After this process cell division
starts within 24 to36 hours. Cleavage
continues to form 2,4,8,cells. In 8th cell stage
process of compaction occurs to get 1st
embryo shape. 16th cell stage called morula.
Next stage called blastula which is 150 cells
stage. It is of 1.5mm in length and 3 to 5
days old it has inner cell mass which forms
fetus & outer cell mass which forms yolk
sack. On 5th day blastocyte starts
penetrating endometrium & at 14th day it get
implanted it self into uterine wall.

orembryoblast
utenneepithelium Uterinestroma
~,~~",".
Trophoblastcells

Timeo!
DNA
duplicatiof
Endometrium(progestational stage)
.,,.< ---I.,I

PERIOD OF EMBRYO(14th
day to 56th day)
• It is the period where major development of
organ specifically craniofacial structure occur. On
17th day process of gastrulation occurs to form
different germ layers. Ectoderm above notochord
thickens to form neural plate which forms
nervous system . On 21st day embryo is of 3mm
now primordial of brain eye are seen in
prosenceophalon. On 3rd day otic &optic
plocodes are seen. In the same period most
inferior part of prosencephalon starts growing to
from front nasal process which overhangs
future oral cavity which is wide & shallow.www.indiandentalacademy.com

Amnion
Wallo!
yolk sac
Primitive pit and
neurenteric canal
A
Cloacal plate
(membrane)
Notochordal plate
c Endoderm
Intraembry onic mesoderm
k sac
A
Cloacal plate
(membrane)
Notochordal plate
c Endoderm
E
Extraembry onic
mesoderm
Notochord
-,u :1I"e+r~t;na for,
mnion
allo!
k sac
A
Cloacal plate
(membrane)
Notochordal plate
c Endoderm
Extraembry onic

,f/,'~
M.
W,'.
:~:i:
:> "-'.~
,

On 3-4week oral groove starts deepening.
At the same time buds for max. and mand.
processes show their presence lateral to
oral groove. Deepened oral cavity is now
called stomodium and is separated by hind
gut with a membranes formed by
endoderm and ectoderm called
buccopharyngeal membranes. On 4th week
the embryo is 5mm. Now frontal elevation
shows some ectodermal proliferation which
form future nasal placode and olfactory
epithelium. Optic placodes which are
formed are placed very widely apartwww.indiandentalacademy.com

Otic placode
Lens
placode
Limb
ridge
B
28 days

• Front nasal process show more growth
mesially than laterally which forms medial
nasal process. As medial nasal process
grows faster, in future it unites with
maxillary process to form part of upper lip
specifically along line of philtrum. Lateral
nasal process mainly contribute formation
of columella. On 5th week caudal to fronto
nasal and maxillary process brachial arches
show their development they are totally six
with 5th one turning to be rudimentary. 2nd
brachial arch develop faster than other and
covers other brachial arches

Cartilage
Ectodermal
epithelium.
esenchymal tissue in
4th arch
Pharyngeal pouch
Endoderma! epithelium
;
Nerve
J
1 st pharyngeal
arch
cleft
2nd arch with nerve,
artery, and
c<1rtllage
A

Auditory tube
External
auditory
meatus
Ventral side of
phary nx
Primitive
tympanic
cavity
Palatine tonsil
- Foramen cecumf
f
,

I
f
!
I
f
,
I
,
'¥Superior parathy roid gland
(f rom 4th pouch)
Thy roid gland
Inf erior parathy roid gland
(f rom 3rd pouch)
Ultimobranchial body
Foregutwww.indiandentalacademy.com

Same time between and around primordial of
brian and eye Mesenchymal condensation
appears which gives a shape of skull.
Mesenchyma of brachial arch also appears by
5th week. 1st brachial grows faster to become
distant. In 6th week mandibular arch show
accentuated growth to divide in maxillary
and mandibular process both process
grows medially. Medial nasal process from
above also grows downwards and towards
midline as a result by the 7th week fusion
between maxillary and frontonasal process
occurs and this time embryo is 14.5mm in
length. www.indiandentalacademy.com

• Now eye starts migrating towards midline
Mesenchymal of cranial and brachial arch
differentiates into cartilage (CHONDRIFICATION)
• Cartilage in the base of skull thins to join with
nasal and optic capsules. Same time centers for
endochondral ossification appears in the
cartilage of base of skull, also, mesenchymal
condensation in intramembranous bone is seen.
At 8th week nasal septum further narrows to
become a prominent structure ,also external ear
starts its development. Nasal pit breaks down to
form nostrils. Demarcation seen between lateral
nasal and maxillary to form nasolacrimal groove
which in future closes to form nasolacrimal duct .www.indiandentalacademy.com

• Primary palate starts its development at
8th week. So till this time their occurs a
direct communication between oral and
nasal cavity. Lidless eyes increase their
movement towards midline. Both lateral
halves of mandibular process fuse by 8th
week. at this time embryo is 18mm in
length.
• Rough head and face shape is almost
completed by 8th week . By end of 8th
week embryo increases in length almost
by 4 times to that of 7th week

 main structures formed in the embryonic
period are
 neural plate –2, buccopharyngeal
membrane -2
 mandibular arch –3
 hypoglossal muscle—5, median and
lateral nasal process-5, lens of eye-5,
retina—5
 external carotid artery-6, middle ear-6,
larynx –6, maxillary process –6, external
ear –7,
 nasal septum-8, palatal shelves-8.www.indiandentalacademy.com

FETAL PERIOD
(56days--9 months )
• Eye lid formation occurs .eyes get close .
nostrils are formed.
• This period shows accelerated rate of
craniofacial growth resulting in an increase
size and proportion In 8th to 12 weeks fetus
increases in length by 22—60mm.
• Mandible increases in size and
anteroposterior relationship of both jaws
develop as it is seen at birth.

• Development of tongue
• Appears in embryo at 4th week of IUL . in the
form of two lateral swellings and one median
swelling that is tubercular impar. All are from
1st pharyngeal arch.
• Another median swelling copula
(hypobranchial eminence) from 2,3 and 4th
arch. Posterior part of 4th arch gives rise to
epiglottis.
• Two lateral swellings grows medially and
anteriorly and overgrows on TI. both half
meet each other to form anterior two third of
tongue.
• Muscles of tongue develop from occipital
myotomes. www.indiandentalacademy.com

Thyroid gland
• Thyroid appears as epithelial
proliferation of in the floor of tongue
between TI and HE.
• Then it descends in front of pharyngeal
gut and forms bilobed diverticulum's
which forms two lobes.

GROWTH OF CRANIAL BASE
• As we have seen that by 4th to 8th week of
IUL evidence of cranial base formation is
seen. The Mesenchymal form is derived
from primitive streak of neural crest and
occipital schlerotomes.
• Condensed mesenchyma forms capsule
around brain called ectomenix basal
portion of this capsule gives rise future
cranial base. The process by which
ectomeningeal capsule get convert into
cartilage is called chondrification .
• It mainly occurs in 4 regions.www.indiandentalacademy.com

Para chordal—around cranial end of
notochord
Hypophyseal—it occurs in 4 centers
• post sphenoid—body of
sphenoid
• pre sphenoid –body of sphenoid
• mesethmoid---plate of ethmoid
cristagalli orbito sphenoid---lesser
wing
• ali sphenoid – greater wing
• Nasal-nostril
• Otic-mastoidwww.indiandentalacademy.com

OCCIPITAL BONE
It ossifies both endochondrally and
intramembranously. It has 2 intra
membranous centers and 5 endochondral
centers.
supra nuchal sq. part – one pair ---8th
week
infra nuchal sq.part --1 pair -------10th
week
basilar part –single median center --
11thweek
foramen magnum occipital condyle ---1
pair –12th weekwww.indiandentalacademy.com

TEMPORAL BONE
It has 11 centers of ossification
Sq, part –1 center (IM)—8TH week
Tympanic ring 4 centers (IM)------12th
week
Petrous temporal bone ---4 centers
(EC)-----5th month
Styloid 2 centers (EC) 5th month
ETHMOID BONE
Its an endochondral bone with 3 centers
Median floor of anterior cranial
fossa –1 centers
Nasal capsule 2 lateral centerswww.indiandentalacademy.com

• SPHENOID BONE
• It has 15 centers of ossification
• Lesser wing –2 orbito sphenoidal
cartilage
• Greater wing ,lateral pterygoid plate-
2(IM)1alisphenoid
• Median pterygoid plate -2 secondary
cartilage of hamular
process
• Anterior part of body of sphenoid- 5
(EC)
• Posterior part body of sphenoid - 4
(EC)
• Cranial base chndrocraniam is

• FLEXURE OF CRANIAL BASE
• In early fetal period cranial base becomes
flexed in the region between pituitary fossa
and sphenooccipital junction this is
accompanied by developing brain stem so
that spinal chord and foramen magnum
directed downwards from their initial position
of backwards this adaptation only seen in
human beings
• It increases neurocranial capacity
• It facilitates predominant downward growth
of face
• At 10th week of intrauterine life flexure angle
is 65 degrees with then flattens. anterior and
posterior part of cranial base grows at
different rates that is between 10th to 40th
week anterior cranial base increase in width

• Development of palate
• Main part of palate arise from maxillary
process & small premaxilla is formed by
deeper part of medial nasal process.
initially medial nasal process gives rise to
small triangular projection which forms
futer premaxilla .then from maxillary
process lateral segments arise which are
placed vertically. In this period mandible
is small & already formed tongue is
pushed upwards in nasal cavity so lateral
segments of maxillary process grow
vertically .

• Nasal septum from above starts growing
downwards & backwards by 7th week of
IUL . Mandible shows accelerated growth
so tongue falls back & transformation of
position of palatal selves occurs from
vertical to horizontal this transformation
takes place within hrs .
• Both palatal selves properly approximate
by 8 ½ to form hard palate & posterior part
use to form sot palate entire palate does
not close at once . initial contact occurs in
central region of secondary palate
posteriorly to pre maxilla from this point
closure occurs both anteriorly
&posteriorly also from above end of nasal
septum fuses with palate .
th

• development o maxillary sinus
• It is formed around at 3rd month of
IUL It develops by expansion of nasal
mucous membrane into maxillary
bone
• It enlarges later by internal
resorption of wall of maxilla

• meckels cartilage
• it derived from first brachial arch on 41st
to 45th day of IUL .extends from
cartilaginous otic capsule to sysmphysis
.it acts as template and guide for growth
of mandible . a major portion of this
disappears and remaining part develops in
to
• mental ossicle
• incus, malleus
• spine of sphenoid
• ant. Ligament of malleus
• sphenomandibular ligament
• 1st structure that develops in promordia of
man. Is mandibular division of 5th nerve

• on 6th week of IUL single ossification
center for each man. Arise in the region of
bifurcation of inferior alveolar nerve in to
mental and incisive. ossifying membrane
is located lateral to meckels cartilage .IM
ossification spreads dorsally and ventrally
to form body and ramus of man.
Ossification continues till region of future
linguala. meckels cartilage continues into
middle ear and develops in to auditory
ossicle that is malleus and incus and SML

• Endochondral bone formation in man.
Seen in3 areas
• condylar process
• mental region
• coronoid process
• condylar process; at 5th week of IUL
mesanchymal condensation seen above
ventral part of man. By 10th week it
develops into cone shaped cartilage. by
14th week it starts ossifying. it then
migrates inferiorly and fuse with man.
Ramus by4th months . by 6-7 th month of
IUL much of cartilage ossifies except
upper end which ossifies at adult hoodwww.indiandentalacademy.com

• mental region
• on either of symphysis 2 small cartilage
appears in 7th month of IUL .it then
incorporates into body . symphysis
ossifies after 1yr after birth
• coronoid process
• it is formed by secondary cartilage.
appears at 10-14th week of IUL. it grows as
response to temporalis muscle. it then join
with ramus

• TMJ
• In IUL it develops in three phases
• Blastamic stage (7—8th week)
corresponds with organization of condyle
,articular disc and capsule
• Cavitations stage (9—11th week) initial
formation of inferior joint cavity
• Maturation stage (from 12thweek)
• At birth articular disc is flat but it then
transforms into S shape
• Articular disc at birth is 1.5mm thick. it
then thins down and replaced by
endochondral ossification
• It grows in post . sup. Lat. Direction

• POST NATAL DEVELOPMENT
AND GROWTH
• Maxilla and mandible are attached to
cranial base by means of sutures
and TMJ respectively. so any growth
change in CB affect growth of jaw

• cranial base
• CB grows post natally by complex interaction
between
• 1) cortical drift and remodeling
• 2) elongation at synchondrosis
• 3) sutural growth
• cortical drift and remodeling ; remodeling is
apposition or resorption of bone which bring
about change in size shape and relationship of
bone
• cranial base is divided into many components
by bony elevations called ridges .These ridges
show bony deposition and other part show
resorption by this process CB develops
• in the area where blood vessels and nerves pass
CB ,show cortical drift ie by bone deposiotion and

• elongation of synchondrosis
•
• cartilage at various junction of bone
called SY
• they act as important growth sites as
they are primary cartilages
• main synchondrosis are
• sphenooccipital
• sphenoethmoid
• intra sphenoid
• intra occipital

• spheno occipital SY ; it is active up to age
12—15years .these segments fuse in
midline by 20yrs . it shows pressure
adapted bone growth. direction of bone
growth at SY is upwards so it carries ant.
Part of cranium bodily forwards closure of
this SY occurs at 13-15yrs
• spheno ethmoid : it ossifies at 5-25yrs
• intra sphenoid : it ossifies at birth
• intra occipital:ossifies at 3–5yrs
•

• sutural growth : --
• growth seen sutures are
• spheno frontal
• fronto temporal
• sphenoethmoid
• frontoethmoid
• frntozygomatic
• main timing of CB growth
• by birth 55%-60%
• 4—7yrs 94%
• 8—1yrs 98%

»post natal growth of
maxilla
– nasomaxillary complex grows by
• displacement
• growth at suture
• surface remodeling
• displacement: as before discussed maxilla
attached attached CB by sutures so as CB
grows secondary displacement is seen in
NMC in downwards and forwards
direction . it mainly seen at 6—12yrs age.
growth at tuberosity seen in postrior
direction to shift maxilla in forwards
direction

• growth at suture
• main sutures at which growth seen are
• frontonasal
• frontomaxillary
• zygomaticotemporal
• zygomaticomaxillary
• pterygopalatine
• these sutures are obliquely placed and by
this maxilla grows in forwards and
downwards direction . soft tissues carry
maxilla also in same direction

• surface remodeling ;
• the remodeling changes seen in NMC.
• resorption occurs on lat. Surface of orbital region
so that eye moves laterally .on medial rim
deposition seen
• floor of orbit due to remodeling grows in sup .lat.
and ant. Direction
• bone deposition occurs on posterior margin of
maxillary tuberosity which causes lengthening of
dental arch and enlargement of antero posterior
dimension of entire maxilla
• bone resorption seen on lateral wall of nose to
increase size of nasal cavity
• bone resorption seen in floor of nasal cavity and
deposition in palatal side so net downward shift
occurs leading to increase in maxillary height

• zygomatic bone moves in posterior
direction by resorption on anterior surface
and deposition on posterior surface
• face enlarges in width by formation of
lateral surface of zygomatic arch and
resorption on medial surface
• anterior nasal spine increase in
prominence by deposition
• tooth eruption ,increase maxillary height
by alveolar bone deposition
• entire wall of sinus except mesial wall
undergoes resorption by which maxillary
sinus increase in size

• post. Natal growth of man.
• Of facial bone man. Has largest amount of
growth post natally
• Ramus : it moves posteriorly by bone
remodeling
• Resorption occurs in anterior part and
deposition occurs in posterior region so it
results in post . drift
• Body of man.: its growth depends on
remodeling growth of ramus so former
ramus converts into posterior body

• Angle of mandible
• On lingual side of angle resorption takes place on
posteroinferior aspect and deposition occurs in
anterosuperior aspect on buccal side exactly
opposite process occurs this results in flaring of
angle of mandible as age advances
• Lingual tuberosity : it is vary similar to maxillary
tuberosity grows posteriorly and lingually
• Alveolar bone grows as tooth erupts in oral cavity
• Chin in infancy is under developed due to position
of head and precordial bulge its growth mainly
influenced by sexual and specific genetic factor
• Males have prominent chin
• In childhood mental protuberance forms and
ossifies its prominence is accelerated by bone
resorption that occurs in alveolar region which

• Condyle : it is main growth site its growth has 2
schools of thought
• Earlier it was believed that growth occurs at
surface of condyle by bone deposition so condyle
grows towards CB condyle pushes against CB
.so entire man. Is displaced forwards and
downwards
• Now it is believed that growth of soft tissue that
is muscle and CT carry man. forwards away from
CB ( carry away phenomenon) and bone grows
secondarily to maintain contact with CB .
condylar growth which peak at 12—14yrs and
stops at 20yrs
• Coronoid process : it follows enlows V principle
, deposition occurs on lingual surface and with it
vertical dimension also increase so it gets a

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Craniofacial growth

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