Development of naso maxillary complex /certified fixed orthodontic courses by Indian dental academy


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Development of naso maxillary complex /certified fixed orthodontic courses by Indian dental academy

  1. 1. Gr owt h and Dev el opm ent of Nas om axi l l ar y c om ex pl INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. DR. GOTTLIEB Is there good growth and bad growth?  DR. ENLOW Well, no. Growth for any individual is "normal", given the circumstances that exist for that individual. Growth is a process striving toward a state of functional equilibrium, and it is always responsive to the conditions that occur, unless pathology is involved. Most structural dysplasias, of course, are in Source: JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1983 "equilibrium".  Oct(669 - 679): JCO/lnterviews: Dr. Donald H. Enlow on Craniofacial Growth
  3. 3. Gr owt h and development of Nasomaxillar y complex         Anat omy Pr e nat al gr owt h Post nat al gr owt h Theor ies Nasomaxillar y r emodeling Clinical implicat ions Ar t icles Summar y
  4. 4. Area of Nasomaxillary Complex
  5. 5. Anatomy Skelet al Tissues / Bones • Maxilla • Zygomat ic • Palat ine • Lacr imal • Vomer • Nasal spine, sept um • Et hmoid • Sphenoid
  6. 6. Sinuses • • • • • Anatomy Maxillar y Fr ont al Et hmoid Sphenoid Nasal cavit y  Radiological appear ance
  7. 7. Anatomy • • • • • • • Ext er nal anat omy of t he nose Muscles at t achment s Blood supply Ner ve supply Lymphat ic Hist ological f eat ur es Relat ion t o sur r ounding st r uct ur es
  8. 8. Anatomy Of Maxilla  Two maxillae ar t iculat e t o f or m 1. Whole upper j aw. 2. Roof of or al cavit y. 3. Gr eat er par t of buccal r oof , f loor and lat er al wall of nasal cavit y and par t of nasal br idge. 4. Gr eat er par t of f loor of t he or bit . 5. I nf r at empor al and pt er gyopalat ine f ossae 6. I nf er ior or bit al and pt er ygomaxillar y f issur es
  9. 9. Anatomy Of Maxilla  Par t s of Maxilla 1. Body –Lar ge and pyr amidal in shape . FR ONTAL 2. Four pr ocesses P ALATINE ZYGOMATIC ALVEOLAR MAXILLA HOUSES THE LAR GEST SINUS OF THE FACE THE MAXILLAR SINUS Y
  10. 10. Maxilla – Medial View Frontal process Maxillary sinus Maxillary process [palatine] Horizontal plate of palatine Palatine process[maxilla] Alveolar process
  11. 11. Maxilla - Lateral View Frontal process Nasal notch Zygomatic process ANS Alveolar process
  12. 12. Maxilla
  13. 13. Anatomy Of Maxilla
  14. 14. Anatomy Of Maxilla 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. nasal f rontal ethmoid sphenoid maxilla horizontal process of palatine superior concha (ethmoid) middle concha (ethmoid) inf erior concha sphenopalatine f oramen medial pterygoid plate pterygoid hamulus of medial plate
  15. 15. Anatomy Of Maxilla At bir t h Adult
  16. 16. Palatine bone
  17. 17. Palatine Bone Hor izont al plat e Per pendicular plat e Pyr amidal pr ocess Or bit al pr ocess Sphenoidal pr ocess
  18. 18. Zygomatic Bone Cheek pr ominence Lat er al wall of or bit I nf r at empor al f ossa 3 For amen 3 Muscles Fr ont al pr ocess – lateral palpebral, suspensory ligament. Tempor al pr ocess
  19. 19. Zygomatic Bone
  20. 20. Lacrimal Bone Smallest – most f r agile Ar t iculat es wit h Maxilla Fr ont al bone Et hmoid bone Nasal concha
  21. 21. Nasal Septum The nasal sept um is made up of t he f ollowing: per pendicular plat e of et hmoid vomer maxilla sept al car t ilage Muscles at t ached t o Nasal bones – Pr ocer us and nasalis.
  22. 22. Vomer Tr apezoid Post er ior par t of nasal sept um
  23. 23. Ethmoid Lat er al masses wit h air cells ossif ied at bir t h Nasal sept um par t ossif ies dur ing 1st yr Cr ibr if or m laminae ossif y in 2nd yr Cr ist a galli bet ween 2nd &4t hyr These car t ilages f use wit h t he lat er al masses in t he 6t hyr
  24. 24. Sphenoid Thr ee par t s Body Lesser wing Gr eat er wing wit h t he pt er ygoid pr ocesses f use dur ing t he 1st yr Spheno-occipit al synchondr osis begins af t er puber t y
  25. 25. External nose • • • Cover ed by t he int egument , and lined by mucous membr ane   The bony f r ame-wor k occupies t he upper par t of t he or gan; it consist s of t he nasal bones, and t he f r ont al pr ocesses of t he maxillæ.   The car t ilaginous f r ame-wor k (car aginesnasi) consist s til of f ive lar ge pieces car t ilage of t he sept um, t wo lat er al and t he t wo gr eat er alar car t ilages, and sever al smaller pieces, lesser alar car t ilages The car t ilage of t he sept um (car agosepti nasi) is til quadr ilat er al t er med t he septum mobile nasi.
  26. 26. External nose
  27. 27. External nose
  28. 28. Para nasal Sinuses Maxillar y sinus Fr ont al sinus Et hmoidal sinus Sphenoidal sinus
  29. 29. Maxillary sinus Pyr amidal shaped Base - lat er al wall of t he nasal cavit y Apex - int o t he zygomat ic pr ocess Aver age - 14.75cc Floor of sinus is above t hat of nasal cavit y at bir t h Sinus incr eases 3t imes ant post & 5t imes in height and widt h I n t he inf er ior end of t he uncinat e pr ocess, is t he ostium maxillare, or opening f r om t he
  30. 30. Frontal sinus • • • • • • • • • The Frontal Sinuses (sinu fr es) s ontal Behind t he super ciliar y ar ches Aver age measur ement s ar e as f ollows: Height , 3 cm Br eadt h, 2.5 cm Dept h f r om bef or e backwar d, 2.5 cm Opens int o middle meat us of t he nose t hr ough t he f r ont onasal duct Absent at bir t h, t hey ar e gener ally f air ly well developed bet ween t he sevent h and eight h year s Reach t heir f ull size af t er puber t y
  31. 31. Ethmoidal sinus The Ethmoidal Air Cells (celuae ll eth es) moidal Et hmoidal labyr int h and complet ed by t he f r ont al, maxilla, lacr imal, sphenoidal, and palat ine bones Thr ee gr oups, anterior, middle, and posterior The ant er ior and middle gr oups open int o t he middle meat us of t he nose The post er ior cells open int o t he super ior meat us www.indiandentalacademy.comet al lif e. Develop dur ing f
  32. 32. Sphenoidal sinus • • • • • • • • The Sphenoidal Sinuses (sinu sph es) s enoidal Aver age measur ement s Ver t ical height , 2.2 cm Tr ansver se br eadt h, 2 cm Ant er o-post er ior dept h, 2.2 cm Communicat es wit h t he sphenoet hmoidal r ecess Minut e cavit ies at bir t h Development t akes place af t er puber t y
  33. 33. Nasal Cavity The nasal chamber s ar e sit uat ed one on eit her side of t he median plane They open in f r ont t hr ough t he nar es, and communicat e behind t hr ough t he choanæ wit h t he nasal par t of t he phar ynx Nares ar e somewhat pear -shaped aper t ur es, each measur ing about 2.5 cm - ant er o-post er ior ly and 1.25 cm t r ansver sely at it s widest par t Choanae ar e t wo oval openings each measur ing 2.5 cm. in t he ver t ical, and 1.25 cm. in t he t r ansver se dir ect ion in a well-developed adult skull
  34. 34. Radiological appearance
  35. 35. Indices • • • • • • • Cephalic index Tot al f acial index Upper f acial index Nasal index Or bit al index Palat al index Gnat hic index
  36. 36. Para nasal Sinuses
  37. 37. Relations with surrounding tissues • • • • • • I nf r at empor al f ossa Pt er gyopalat ine f ossa Basicr anium Middle ear Or al cavit y Nasophar ynx
  38. 38. Muscle attachments
  39. 39. Blood vessels, Nerves & Lymphatics External carotid artery V & VII cranial nerve Submandibular lymphnodes
  40. 40. Histological Appearance Olf actory cells, olf actory hairs and glands of B owman, ar e ident ical in st r uct ur e wit h ser ous glands The epit helial cells of t he nose, f auces and r espir at or y passages play an impor t ant r ole in t he
  41. 41. Development of Embryo • 1st week – 3 rd week • Ovum Zygot e Blast ocyst Gast r ula Neur ulat ion
  42. 42. Development of Embryo 4 t h week Somit es Neur al t ube f or mat ion 24 t h day 1st and 2 nd ar ch ar e dist inct 26 t h day – 3 pair s of br anchial ar ches ot ic pit s appear 4 t h pair of br anchial ar ches and lens placodes ar e visible • C shaped cur vat ur e of t he embr yo
  43. 43.
  44. 44. Branchial Arches  1st • • Arch - Mandibular Arch 2 pr ominences - mandibular pr ominence - maxillar y pr ominence Bones – mandibular , maxilla, zygomat ic squamous par t of t he t empor al bone malleus incus
  45. 45. Branchial Arches  1st Arch - Mandibular Arch • Muscles of mast icat ion Mylohyoid and ant er ior belly of digast r ic Tensor t ympani Tensor veli palat ine Ant er ior ligament of malleus Sphenomandibular ligament Trigeminal nerve except the opthalmic division Maxillary artery Meckel’s cartilage • • •     
  46. 46. Branchial Arches  2nd • Arch - Hyoid Arch Bone - hyoid st apes st yloid pr ocess lesser cor nu of hyoid upper par t of body of hyoid
  47. 47. Branchial Arches  •    2nd Arch - Hyoid Arch Muscles of f acial expr ession st apedius st ylohyoid post er ior belly of digast r ic st ylohyoid ligament Facial nerve Stapedial artery R eichert’s cartilage
  48. 48. Branchial Arches  • •    Thir d Ar ch Bone – gr eat er cor nu and t he inf er ior par t of t he body of t he hyoid bone St ylophar yngeus Glossopharyngeal nerve Common carotid artery Internal carotid artery Carotid body
  49. 49. Branchial Arches  Fourth • •   Arch Thyr oid car t ilage cor niculat e cunief or m car t ilage Muscles – cr icot hyr oid, const r ict or s of phar ynx, palat ophar yngeus, uvular muscles of sof t palat e, palat oglossus Superior laryngeal nerve Lef t – arch of aorta & R ight – subclavian and brachiocephalic arteries
  50. 50. Branchial Arches  Sixth arch • Cricoid cartilage arytenoid cartilage • R ecurrent laryngeal nerve
  51. 51. P natal growth and re development
  52. 52. Prenatal embryology 1/ 3 r d Pr ominence • Face - Upper - Fr ont onasal - Middle - Maxillar y - Lower - Mandibular Or ganizing cent er s Pr osencephalic - Upper t hir d of f ace Rhombencephalic - Middle t hir d of f ace
  53. 53. 4th week IUL • Shallow depr ession - Pr imit ive mout h - St omodeum • Floor of t he st omodeum is f or med by t he Buccophar yengeal membr ane
  54. 54. Pre-natal growth  At f ourth week of of IUL1.migr at ion of neur al cr est cells 2.f or mat ion of br achial ar ches FR ONTONASAL MAXILLAR Y MAXILLAR Y STOMODEUM MANDIB ULAR MANDIB ULAR
  55. 55. Medial nasal process Lateral nasal process Maxillary process Mandibular process
  56. 56.  Maxillar y and Mandibular pr ocessesf irst branchial arch  Fr ont onasal pr ocesses- downward prolif eration of mesenchyme of developing brain Medial nasal Lateral nasal maxilla mandible Mesenchyme of first arch zygomatic palatine Part of temporal
  57. 57. Nasal process Lat er al nasal pr ocess Median nasal pr ocess
  58. 58.  At Seventh Week IUL1.For mat ion of upper lip 2.I nt r amembr anous Bone ossif icat ion Takes Place 3.For mat ion of Nasal Sept um 4.Nasolacr imal Duct 5.For mat ion of Pr imar y Palat e
  59. 59. At Seventh Week IUL  Pr imar y ossif icat ion cent er -f or each maxilla at t er minat ion of inf r aor bit al ner ve above canine t oot h dent al lamina. zygomat ic  Secondar y cent er int er maxillar y or bit onasal nasopalat ine
  60. 60. At Eighth Week IUL  Two int er maxillar y ossif icat ion cent er s gener at e t he alveolar r idge and pr imar y palat e  I nt r amembr anous ossif icat ion cent er s appear f or ; -Nasal and lacr imal bones. -Medial pt er ygoid plat e of sphenoid. -Vomer . -Zygomat ic bone
  61. 61. Twelf th Week  Ant er opost er ior maxillo- mandibular r elat ionship appr oaches t hat of newbor n inf ant  Maxilla incr eases in height
  62. 62.
  63. 63.
  64. 64. Growth of palate  1st t r imest er -nar r ow  2 nd t r imest er -moder at e widt h  3 rd t r imest er - wide  Br eadt h>lengt h  Height changes less dr amat ic
  65. 65. Growth of palate • Two pr imor dia, pr imar y palat e and secondar y palat e
  66. 66. Pre-natal Growth and development of palate  For mat ion palat e  Elevat ion  Fusion of pr imar y and secondar y of palat al shelves of palat al shelves
  67. 67. Early palate formation  28 t h day of I UL  -disint egr at ion of buccophar angeal membr ane Oral cavity  st omadeal chamber Nasal cavity  Hor izont al ext ensions 2 palatal Single primary shelves palate
  68. 68.  St r uct ur e of palat e P rimary palate Secondary palate  5 TH week IUL PALATOGENESI S 6 9 CRI TI CAL PERI OD 12 TH week IUL
  69. 69. Primary palate Frontonasal process Medial nasal Mesenchyme P maxilla re- Wedge shaped mass between P rimary palate internal surf ace maxillary of
  70. 70. Primary palate Pr i m y ar pal at e
  71. 71. Secondary palate Maxillary prominence 2 horizontal mesenchymal projecti Lateral palatine process Fuse- With each other P rimary palate Nasal septum Secondary palate
  72. 72. Secondary palate Palat al Shelves
  73. 73. Elevation of palatal shelves At 6 weeks 1. Tongue {undif f er ent iat ed t issue} pushes dor sally 2. palat al shelves become ver t ical 3. Elevat ion occur s f r om ver t ical t o hor izont al posit ion 
  74. 74. Elevation of palate H s t ol ogi c al s ec t i Nas al s ept um Pal at al s hel v es Tongu e
  75. 75. At 8 weeks Muscular movemen t Vascular changes Intrinsic shelf f orce P ressure dif f erenc es B iomechanical transf ormation Increase in Elevation of palatal shelves tissue turger Dif f erential mitotic growth Withdrawal of embryo’s f ace
  76. 76. Elevation of head and lower jaw
  77. 77.
  78. 78. Fusion of palatal shelves
  79. 79.
  80. 80.
  81. 81. Fusion of palate Incisive f oramen Mid palatine raphe
  82. 82.
  83. 83. Formation of palate [summary] Pr imor dium For me of d by Pr imar y palat e Secondar y palat e Pr e maxilla Der ive d f r om Median Fr ont onasal palat ine pr ocess pr ocess Har d Lat er al Maxillar y and palat ine pr ocess sof t pr ocess palat e
  84. 84. Ossification of the palate • 8th wk • 10th wk • Childhood • • Pr emaxillar y cent r es Pr imar y ossif icat ion cent r es of each palat ine bone Y shaped midpalat al sut ur e T shaped midpalat al sut ur e No ossif icat ion at t he sof t palat e r egion
  85. 85. Musculature of palate  Tensor veli palat ini 40 days ar ch  Palat ophar angeous 45 days  Levat or veli palat ini 8 t h week ar ch  Palat oglossus 9 t h week  Uvular muscle 11t hweek ar ch 1st 2 nd 2 nd
  86. 86. Growth in dimensions height width length  Lengt h  Widt h Arched palate - 7-8 weeks I UL - 4 t h mont h onwar ds
  87. 87. Growth in dimensions  Pr e nat al lif e (appositional growth in the alveolar margin) lengt h > widt h  At bir t h (appositional growth in the maxillary tuberosity) lengt h =  Post widt h nat al lif e widt h > lengt h
  88. 88. Factors af f ecting growth of palate  Elevat ion of head and lower j aw  Oxygen and nut r it ional def iciency  Excess endocr ine subst ances  Dr ugs t er at oge ns  I r r adiat ion  Vascular it y
  89. 89. Maxillary sinus  PRE NATAL  lat er al evaginat ion of mucous membr ane in middle meat us –3 rd mont h I UL  AT BI RTH  2mm -long, 1mm in widt h + height  PNEUMATI SATI ON P IMAR R Y SECONDAR Y
  90. 90. Neonatal Skull
  91. 91. Clef t Lip and P alate
  92. 92. Genesis of clef t lip and palat e  Associat ed wit h mor e t han 150 syndr omes  Aet iology • Mut ant gene or chr omosomal aber r at ions - Monogenic - Polygenic
  93. 93. Inf ectio us agents Irradiation Drugs Etiology of clef t lip / palate Nutritional def iciency Excess hormones Smoking and alcohol
  94. 94. Genesis of clef t Separ at ion due t o wide gr owing br ain and cr anial f loor • Separ at ion due t o t ongue • Biochemical or t issue bar r ier int er cedes bet ween t he f using par t s • Pr imar y f ailur e in t he f usion •
  95. 95.
  96. 96. Clef t lip usually seen at t he philt r um and t he lat er al par t of t he upper lip Har elip Bif id nose
  97. 97. Prenatal anomalies Formation of germ layers Day 17 Fetal alcohol syndrome [mid f ace def iciency] Migration and prolif eratio n of cell population Day 1928 Treacher Collin syndrome
  98. 98. Prenatal anomalies P rimary palate 28- 38 f ormation days Clef t lip /clef t palat other f acial clef ts Clef t palate/synostosis Secondary palate f ormation Crouzon syndrome 42- 55 Epithelial pearls days Torus palatinus High arched palate
  99. 99. Ot her syndr omes • • • • • • • • Downs syndr ome Hur ler s syndr ome Cebocephaly Scaphocephaly Aper t syndr ome Cyclops Van der Woude syndr ome Cr aniost enosis
  100. 100. ANOMALIES OF P ALATE  Epit helial pear ls
  101. 101. ANOMALIES OF P ALATE  Tor us palat inus
  103. 103. Genesis of clef t palat e     Delay in shelf elevat ion Dist ur bance in mechanism of shelf elevat ion Failur e of shelves t o cont act due t o lack of gr owt h Failur e t o displace t he t ongue dur ing closur e [ Pier r e Robin syndr ome]
  104. 104. ANOMALIES OF P ALATE  Clef t palat e Failure of f usion of the lateral palatine process with each other or with the median palatine process
  105. 105. Genesis of clef t palate  Failur e t o f use af t er cont act as epit helium does not br eak down  Rupt ur e af t er f usion  Def ect ive mer ging
  106. 106. Types of clef t palate B id if uvula Unilateral clef t palate B ilateral clef t palate
  107. 107. Unilateral clef t palate B ilateral clef t palate B id uvula if
  108. 108.
  109. 109. Classif icat ions  Davis and R itchie’s : (1922) Group I – prealveolar clef ts Group II – postalveolar clef ts : clef t involving hard and sof t palate Group III – Clef t of both primary and secondary palate
  110. 110. Veau’s classif icat ion : (1931) A. Clef t lip class I : U/L notching of vermillion border, not extending into the lip. class II : clef t extending into the lip, but not including the f loor of the nose. class III: extending into the f loor of the nose. class IV: any b/l clef t of the lip,
  111. 111. • • B Clef t palate . class I : sof t palate • class II : sof t/hard palate extending no f urther than incisive f oramen • class III: complete u/l clef t, extending f rom uvula to incisive f oramen, then deviating to one side • class IV: two clef ts extending
  112. 112. Fogh Ander son’s Classif icat ion (1946) 1. Hare lip clef t 2. Hare lip clef t associated with clef t palate 3. Isolated clef t palate
  113. 113. Ker nahan / St ar k’s (1958) 1. Clef t of primary palate 2. Clef t of secondary palate 3. Clef t involving both primary and secondary palate.
  114. 114. I nt er disciplinar y appr oach • • • • • • • • • • • Genecist Orthodontist Oral Maxillof acial Surgeon P rosthodontist P lastic Surgeon P aediatrician Social workers P sychiatrist / P sychologist Speech P athologist / Therapist Audiologist Nursing services
  115. 115. Stage I • • • Maxillary Orthopedic stage – Bir t h t o 18 mont hs Mc Neil – 1950 pr ost het ic devices Obt ur at or False plat e Maxillar y cr oss ar ch st abilit y Maxillar y or t hopedic molding
  116. 116. Pr emaxillar y or t hopaedics – bir t h t o 5 mont hs • 1686 – Hof man • Use of headcap and pr emaxillar y st r ap t o r eposit ion t he pr emaxilla •
  117. 117. Cheiloplast y • Rule of Tens 10 weeks of age 10 pounds of body weight 10 gr ams of hemoglobin •
  118. 118. • Maxillar y or t hopaedics – 3 t o 9 mont hs Obt ur at or t o pr ovide cr oss ar ch st abilit y
  119. 119.  St age II - Pr imar y dent it ion - 18 mont hs t o 5 yr s  St age I I I - Lat e pr imar y or mixed dent it ion – 6 t o 11 yr s  St age 18yr s I V – Per manent dent it ion – 12 t o
  120. 120. Gr af t ing pr ocedur es • Palat oplast y - 1 t o 2 yr s Pr imar y bone gr af t ing < 2 yr s Ear ly secondar y bone gr af t ing – 2 t o 4 yr s Secondar y bone gr af t ing – 6 t o 15 yr s Lat e secondar y bone gr af t ing – Adult • Gr af t f r om RI B - 2cms is har vest ed • • • •
  121. 121. Clinical f eat ur es of clef t palat e  Feeding pr oblems par t icular ly in inf ant s in whom suckling pr ocess demands int act palat e  Nasal voice r egur git at ion/ nasal t wang in  Collapsed  Dif f icult y ar ch in speech and swallowing
  122. 122. Dent al def or mit ies • • • • • • • • • • Nat al or neonat al t eet h Congenit ally missing t eet h Super numer ar y t eet h Ect opic er upt ions Alt er ed t oot h mor phology Def icient alveolar bone suppor t Rot at ions, deviat ions in axial r oot inclinat ions Post er ior cr oss bit e Mobile and pr ot uber ant pr emaxilla Convex pr of ile
  123. 123. P ost natal growth of Nasomaxillary complex
  124. 124. • • • • Gener al f eat ur es Thr ee dimensional gr owt h of maxilla Height (Ver t ical) Widt h (Tr ansver se) Lengt h (Ant -Post ) Theor ies of gr owt h Sut ur al Car t ilaginous Funct ional mat r ix t heor y Key f act or s in Nasomaxillar y r emodelling
  125. 125. Displacement • Pr imar y displacement • Secondar y displacement
  126. 126. Rever sal line • • • Directions of growth sequentially undergo reversals A reversal line showing the crossover between resorptive and depository growth fields seen in microscope Factors affecting reversal shape of bone muscle attachments rotations growthfeilds
  127. 127. Post natal growth of maxilla  Sur f ace r emodeling apposition resorptio n  Displacement CR ANIAL B ASE MAXILLA Tr ans f or m at i on Tr ans l at i on SUTUR ES  MOSS
  128. 128. Post natal growth of maxilla  Mechanism • • • • • of gr owt h Sut ur al Nasal sept um Sur f ace apposit ion and r esor pt ion on per iost eal and endost eal sur f aces Alveolar pr ocess Spheno occipit al synchondr osis
  129. 129. • I n cont r ast t o cr anial base maxilla is dominat ed by intr membanou ossification a r s • E ondr b gr thseen at t he et hmoid ndoch al one ow bone and nasal sept um
  130. 130. Surface apposition
  131. 131. Spheno occipital synchondroses
  132. 132. Post natal growth
  133. 133. Post natal growth At Bi r t h Hard palate : length = width maxillary sinus : radiographically not visible 1 – 2 years Extensive remodeling descent of palate /enlargement of nasal cavity Mid palatine suture growth ceases No synostosis
  134. 134. Post natal growth THE MIXED DENTITION YEAR S Growth in width of the dental arch anterior to the f irst molar Inter canine width completed Mid palatine suture starts closing at 910 years Ceases by 5- 6 yrs 12 yrs - f emales 18 yrs - males RME Best done bet ween 9-14 yr s
  135. 135. Post natal growth THE MIXED DENTITION YEAR S  The deposit or y gr owt h pot ent ial of t he t uber osit y allows f or ar ch expansion by moving t he t eet h post er ior ly int o t he ar ea of bone deposit ion  Ext ensive scope f or gr owt h modif icat ion bef or e adolscent gr owt h spur t
  136. 136. Post Natal Growth THE EAR P MANENT DENTITION YEAR LY ER S •Growth modif ication still possible in boys •R ME can still be tried till 12 - 15 yrs complete •>15 years closure[synostosis] Orthognatic surgery
  137. 137. Age changes  All par a nasal sinuses incr ease in size  Ver t ical height decr eases Al v eol ar pr oc es s r es or bed  Ver t ical Toot h l os s changes > AP > widt h  Sof t t issue changes > skelet al  Nose gr owt h cont inues t ill 25 year s  I nclinat ion of palat al plane incr eases[post downwar ds]
  138. 138. Ef f ect s of Dent it ion and Occlusion • Bimolar widt h in t he 1st molar r egion cor r elat es - Ver t ical gr owt h of maxilla - Gr owt h in t he midpalat al sut ur e - gr owt h in height
  139. 139. Ef f ect s of Dent it ion and Occlusion • • • • Maxilla dr if t s – 5mm f or war d in molar r egion (by adolscence) - 2.5mm in incisor r egion Shor t ening of t he ar ch per imet er – associat ed wit h er upt ion of 2 nd molar I nit iat ion of er upt ion of 3 rd molar occur s af t er t he gr eat est shor t ening of lengt h in t he maxillar y dent al ar ch Shor t ening of ant er ior segment – mesial dr if t of t eet h – cr owding of ant segment – conver gence and nar r owing of t he bone base
  140. 140. Post natal growth of maxilla  Gr owt h in height ver t ical  Gr owt h in widt h t r ansver se  Gr owt h in lengt h A -P
  141. 141. Ver t ical gr owt h • Bjork and Skieller implant studies - height increases because of sutural growth toward the frontal and zygomatic bones - appositional growth in the alveolar bone, floor of orbit, on hard palate and resorption on nasal floor
  142. 142. HEIGHT ENLOW AND BANG ‘V’ PRINCIPLE  Deposition on the oral side  R esorption on the nasal side
  143. 143. V pr inciple of Bang and Enlow Remodeling of palat e  Entire ‘v’ shaped structure moves in a direction towards the wide end of the ‘v’
  145. 145. HEIGHT - V’ PRINCIPLE Sagi t t al Cor onal
  146. 146. HEIGHT P rimary displacement
  147. 147. WIDTH  Finished  WIDTH ear lier in post nat al lif e GROW I N M D TH I PALATI NE SUTURE REM ODELI NG I N TH E LATERAL SURFACE OF ALVEOLAR PROCESS Mut ual t r ansver se r ot at ions of maxillar y halves give palat e ‘u’ shape
  148. 148. WIDTH • This gr owt h mimics t he gener al gr owt h cur ve • Mut ual t r ansver se r ot at ion of t he t wo maxillae r esult s in mor e separ at ion of t he halves in t he post er ior t han t he ant er ior segment
  149. 149. LENGTH  Begins r apidly in t he 2 nd year of lif e Maxillary P alato primary secondary tuberosity maxillary suture displacement
  150. 150. LENGTH Resor pt ion in t he ant er ior r egion of t he maxilla • Maxilla r ot at es in r elat ion t o t he ant er ior cr anial base • Bj or k and Skieller implant st udies have shown t hat ant er ior sur f ace is st able sagit t ally •
  151. 151. Timing Alveolar pr ocess – er upt ion of t eet h • Over all height – along wit h - Ver t ical gr owt h of mandible - Gener al body gr owt h cur ve •
  152. 152. Compensat or y mechanism • • • Nar r ow palat e – alveolar pr ocess compensat es f or widt h and height Deep bit e – Occ plane par allel t o mandibular plane Long ant er ior sur f ace – St eep occlusal plane Adapt ive nat ur e Class I molar r elat ion t hough skelet ally r et r ognat hic Or t hodont ic cor r ect ion t ot ally dependent on t he adapt ive capacit y of alveolar pr ocess r emodelling
  154. 154. Sut ur al Theor y Weinman & Sicher      Sutures have innate growth potential P ush bones apart Oblique in nature Sliding ef f ect R esultant thrust in the anterior and inf erior direction
  155. 155. Sut ur al Theor y Shor t comings - Bone t issue in not capable of gr owt h in a f ield t hat r equir es level of compr ession needed t o pr oduce a pushing t ype of displacement - Sut ur e is essent ially a ‘t ension’ adapt ed t issue - Sut ur es do not have inbuilt gr owt h pot ent ial •
  156. 156. Car t ilagenous t heor y Scot t  Nasal sept um – innat e gr owt h pot ent ial  Thur st ef f ect – sept omaxillar y ligament – gr owt h in f ields of compr ession  Mor e of f or war d and downwar d f or ce t han ver t ical  Bone enlar ges at t he sut ur es in r esponse t o t he t ension cr eat ed by displacement Sur gical r emoval Nasal sept um… 
  157. 157. Removal of nasal sept um –mid f ace def iciency
  158. 158. Car t ilagenous t heor y • • • • Shor t comings Nasal sept um f unct ions t o suppor t t he r oof of t he nasal chamber Doesn’t displace t he palat e by it self Reasons Sour ce of maxillar y displacement is mult if act or ial Expt l st udies mer ely show t hat gr oet h pr ocess f unct ions in it s absence r at her t han in it s pr esence
  159. 159. Funct ional mat r ix hypot hesis Moss FUNCTI ONAL M ATRI X SKELETAL UNI TS  B asal body Inf raorbital nerve  Orbital unit Eyeball  Nasal unit cartilage Septal  Alveolar unit Teeth
  160. 160. Funct ional mat r ix hypot hesis Height R emodelling changes in the orbit Enlarging orof acial capsule Sof t tissues give control signals to genic tissues response seen in the hard tissue
  161. 161. The Counterpart Analysis Growth of any given facial or cranial part relates specifically to other structural and geometric counterparts in the face and cranium” – Enlow As the cranial flexure decreases, the maxilla is translated or displaced forward and downward to give a more protrusive maxillary position.
  162. 162. The Nasomaxillar y Complex Remodeling • • • • • • • • • • • The Lacr imal Sut ur e The Maxillar y t uber osit y Key r idge Ver t ical dr if t of t eet h Nasal air way Palat al r emodelling Downwar d maxillar y displacement Maxillar y sut ur es The Cheekbone and Zygomat ic Ar ch The par anasal sinuses Or bit al Gr owt h
  163. 163. Lacr imal bone • • • • • Bounded by sut ur al connect ive t issue Under goes r emodelling r ot at ion – medial super ior par t r emains wit h t he nasal br idge, inf er ior par t moves out war dly wit h t he et hmoidal sinuses Pr ovides slippage of mult iple bones along sut ur al int er f aces ‘ perilacrimal sutural system’ Maxilla slides downwar ds along it s or bit al cont act s Development al gr idlock would develop wit hout t his syst em
  164. 164. Maxillar y t uber osit y  Est ablished by t he post er ior boundar y of ant er ior cr anial f ossa  Helps in post er ior and hor izont al lengt hening of ar ch Anterior displacement= posterior lengthening lateral widening downward deposition Contributes to maxillary sinus enlargement
  165. 165. Key r idge Ver t ical cr est below t he malar pr ot uber ence ‘muzzle’ Rever sal occur s at t he key r idge Post er ior apposit ion Ant er ior r esor pt ion
  166. 166. Vertical drift of teeth Ver t ical dr if t – signif icant int r insic gr owt h f act or • pr ovides int r amembr anous bone r emodelling • Moves t he t oot h in it s socket – usually called ext r usion • mesial dr if t well known pr ocess – ‘Ver t ical dr if t ’ not a par t of ever yday vocubular y •
  167. 167. Nasal air way Lining surf ace of bony wall and f loor R esorptive (except olf act or y f ossae) Downwar d r el oc at i on of pal at e Lateral and anterior expansion Downward cortical remodelling of entire anterior cranial f loor & lateral and inf erior depositions on ethmoidal conchae
  168. 168. Nasal air way  Ethmoidal conchae - lateral + inf erior deposition - medial + superior resorption  Inter nasal septum - lengthens vertically at sutural junctions
  169. 169. Palat al r emodelling V pr inciple • Bone deposit ion on t he inside of t he ar ch • Gr owt h along t he mid palat al sut ur e • Gr ows inf er ior ly exchange of old palat e f or new har d and sof t t issues occur s •
  170. 170. Downwar d maxillar y displacement • Pr imar y displacement of t he et hmomaxillar y complex inf er ior ly • New bone is added at all sut ur es and t hese sut ur es accompany displacement pr oduced by t he sof t t issues
  171. 171. Downwar d maxillar y displacement • The balance of > or < gr owt h in post er ior and ant er ior maxilla is due t o clockwise/ count er clockwise r ot at or y displacement caused by downwar d and f or war d gr owt h of t he middle cr anial f ossa • Nasomaxillar y complex under goes compensat or y r emodelling r ot at ion t o sust ain it s posit ion r elat ive t o t he ver t ical r ef er ence line and t o t he neut r al or bit al axis
  172. 172. Maxillar y sut ur es • Sut ur es slide or slippage of bones along t he int er f ace • Remodelling and r elinkage of t he collagenous f iber connect ions wit hin t he sut ur al connect ive t issue causes t he displacement pr ocess
  173. 173. Cheek and zygomat ic bone • • • • • Post er ior side of malar pr ot uber ence wit hin t he t empor al f ossa is deposit or y Cheek bone r elocat es post er ior ly as it enlar ges Post er ior r elocat ion slows af t er dent al ar ch lengt h is achieved dur ing childhood Zygomat ic ar ch moves lat er ally by r esor pt ion on t he medial side Zygoma and cheekbone complex ar e displaced ant er ior ly and inf er ior ly in t he same dir ect ions as t he maxilla
  174. 174. Zygomat ic r egion Post er ior r elocat ion ant er io r post er ior I ncr ease in height I nf er io r bor Lat er al gr owt hder f r ont ozygomat ic displacement Zygomat icot empor al [ ant er i Fr ont ozygomat ic [ inf er ior ]
  175. 175. Maxillar y sinus Age changes Expands - 2mm ver t ically 3mm A-P ever y year > in size r esor pt ion in walls + alveolus
  176. 176. Maxillar y sinus P OST NATAL  All internal surf aces resorption [expect medial]  R apid continuous downward growth close proximity to buccal maxillary teeth 
  177. 177. Or bit al gr owt h • • • • • • Most of the lining roof and floor are depository Lateral wall remodels by deposition and medial by resorpition i)Forward remodelling of the nasal and superior orbital rim, ii) backward remodelling of the inferior orbital rim and the malar area iii) downward remodelling of the premaxillary region combine to produce rotation and alignment of the midface and upper facial regions
  178. 178. References  Contemporary orthodontics - PROFFIT  Principles and practice of orthodontics GRABER  Essentials of facial growth - ENLOW  Craniofacial embryology - SPERBER  The developing human - MOORE and PERSAUD  Oral histology and embryology TENCATE  Handbook of orthodontics – MOYERS
  179. 179. References  Moyers – 3rd edition  Dentistry for child and adolescent MAC DONALD  Clinical pedodontics - FINN  Color atlas of EmbryologyMOORE,PERSUAD  Hand Book of Facial Growth-ENLOW  Grays Anatomy – 38th Edition  Previous Seminars By - Dr.Chatura Hegde, Dr Ravi Tej, Dr.Harshavardhan Kidiyoor and Dr Jaya Kothari.
  180. 180. Ability is what you’re capable of doing. Motivation determines what you do. Attitude determines how well you do it. - Lou Holtz
  181. 181. QUANTITATION OF MAXILLAR R Y EMODELING Sh donBau ind,E ar Kor el mr dw d n A JA 1987 JO N  Unif or m displacement of all 3 pt s in ver t ical dir ect ion [downwar d displacement –0.3mm/ year ]  Hor izont al dir ect ion post er ior displacement of all 3 pt s [ however the displacement of P NS was greater than ANS and pt A ]  THE INCR EASE IN LENGTH IS P IMAR R ILY B ECAUSE OF GR OWTH IN P OSTER IOR B DER OR
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