Growth and development of maxilla and maxillary /endodontic courses

GROWTH AND
DEVELOPMENT OF
MAXILLA AND AIR
SINUS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

CONTENTS
• INTRODUCTION
• DEFINITIONS OF GROWTH AND DEVELOPMENT
• THEORIES OF GROWTH
• PRENATAL GROWTH AND DEVELOPMENT OF MAXILLA
• POSTNATAL GROWTH AND DEVELOPMENT OF MAXILLA
• CONTROL PROCESS AND FACTORS AFFECTING GROWTH
• GROWTH AND DEVELOPMENT OF AIR SINUS
• ANOMALIES OF MAXILLA AND AIR SINUS
• PROSTHODONTIC CONSIDERATION
• SUMMARY
• REFERENCES

INTRODUCTION
• It is essential to study the growth and development of maxilla
and maxillary sinus to diagnose and prosthetic management of
the developmental anomalies of maxilla and maxillary sinus
successfully.
DEFINITIONS OF GROWTH
• Krogman : Increase in the size, change in proportion and
progressive complexity.
• Todd : An increase in size.
• Moyers : Quantitative aspect of biologic development per unit
time.
• In general : Growth is increase in spatial dimensions in weight;
it may be multiplicative (increase in size of cells) or
accretionary (increase in the amount of non-living structural
matter) or auxetic / intersuceptive (increase in the size of cells).

DEFINITIONS OF DEVELOPMENT
• Todd: Development is progress towards maturity.
• Moyers : Development refers to all 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. Thus, it encompasses the normal sequential
events between fertilization and death.

Theories of Growth
Major theories are:
• Sicher’s hypothesis or sutural dominance theory.
• Scott’s hypothesis/ cartilagenous theory.
• Moss, Functional matrix theory.
• Van Limborgh’s theory.
• Enlow’s expanding V principle.
• Enlow’s counterpart principle.

Growth and Development of Maxilla
Will be considered in 2 periods:
1. Prenatal period (intra uterine).
a. Preembryonic (0-14 days).
b. Embryonic (14-55 days).
c. Foetal (56-270 days).
2. Post natal period (extra uterine).

Preembryonic period
Male Female
gametes gametes
Zygote
Morula
Blastula

9-day human blasto cyst

Embryonic period (From 1-8 weeks)
It is divided into 3 periods:
1. Presomite (8-21 days) : Germ layers of embryo are formed in
the inner cell mass.
Germ disc at the end of 2nd
week of
development
16 day presomite embryo

17 day embryo

2. Somite (21-31 days) :
Characterized by the
appearance of prominent
dorsal metameric
segments, the basic
patterns of the main body
and systems and organs
are established.

Late somite period:
During the late somite period (4th
week i.u.) the lateral part
of the mesoderm of the ventral foregut region becomes
segmented to form a series of 5 distinct bilateral
mesenchymal swellings, called as pharyngeal arches.
Pharyngeal clefts: Arches are separated by deep grooves
called pharyngeal clefts.
Pharyngeal pouches: Are outpocketings appearing along
the most cranial part of the foregut.

Pharyngeal arches

4 week embryowww.indiandentalacademy.com

• Maxilla is formed from 1st
pharyngeal arch.
Prenatal growth of maxilla
• 1st
pharyngeal arch lying lateral to the stomadeum
divided in 2 processes.
– Dorsal process – Maxillary process.
– Ventral process – Mandibular process.
• Maxillary process, extending forward beneath the
region of the eye and subsequently gives rise to the:
– Maxilla,
– Premaxilla,
– Zygomatic bone and part of the temporal bone.

4 ½ week embryo

• Stomodeum : At the end of 4th
week, the center of the face
is formed by stomodeum.
• Olfactory placodes: Localized thickenings develop within
the ectoderm of the frontal prominence, just rostral to the
opening of stomodeum. These are olfactory placodes.
• Lateral nasal process: The lateral arm of the horse shoe is
called lateral nasal process.
• Medial nasal process: Is the medial aspect of the horse
shoe.
• Frontonasal process: Between the two nasal processes is
depressed area called frontonasal process.

5 week embryo 6 week embryo
7 week embryo 10 week embryowww.indiandentalacademy.com

Intermaxillary Segment
• As a result of the medial growth of the maxillary
swellings, the two medial nasal swellings merge
not only at the surface but also at the deeper level.
The structures formed by the two merged
swellings are together known as intermaxillary
segment.
• It is comprised of:
– A labial component : forms the philtrum of upper lip.
– Upper jaw component : Which carries 4 incisor teeth.
– Palatal component : Which form the triangular primary
palate.

Intermaxillary segment and
maxillary process
Intermaxillary segment with
different components

Secondary palate
• While the primary palate is derived from
intermaxillary segment, the main part of definitive
palate is formed by fusion of 2 shelf like
outgrowths from the maxillary swellings at 6th
week i.u life.
• They attain horizontal position at 7 week and fuse.
• This part of the palate is a direct extension of the
maxilla from which it develops.
• In the meantime, the nasal septum has merged
with the superior surface of the palate. The two
nasal chambers are now completely
compartmented and both have been closed off
from the oral cavity along the length of the palate.www.indiandentalacademy.com

6 ½ week embryo

7 ½ week embryo

10 week embryo

Fetal period
• Fetal period: The beginning from 8th
week until
term.
• Identified by the 1st
appearance of ossification
centres and earliest movement by foetus.
• There is little new tissue differentiation or
organogenesis but there is rapid growth and
expansion of the basic structures already
developed.

• The growth of maxilla depends on influence of several functional
matrices that act upon different areas of the bone thus allowing
its subdivision into skeletal units:
• The BASAL BODY beneath the INFRAORBITAL NERVE,
later surrounding it to form the infraorbital canal.
• The ORBITAL UNIT responds to the growth of the eyeball
• The NASAL UNIT depends on the SEPTAL CARTILAGE for
its growth.
• The TEETH provide the functional matrix for the ALVEOLAR
UNIT
• The PNEUMATIC UNIT reflects maxillary sinus
expansion,which is more a responder than a determiner of the
skeletal unit.
Postnatal Period

• Maxillary tuberosity and arch lengthening.
• Lacrimal suture - A key growth mediator.
• Maxillary tuberosity and the key ridge.
• Vertical drift of teeth.
• Nasal airway.
• Palatal remodelling.
• Downward maxillary development.
• Cheek bone and zygomatic arch.
• Orbital growth.
Nasomaxillary complex

•Maxillary tuberosity and arch lengthening.

Lacrimal suture - A key growth mediator.

•Vertical drift of teeth.

•Nasal airway.

Palatal remodelling.

•Downward maxillary development.

Cheek bone and zygomatic arch.

•Orbital growth.

• The overall growth changes are the result of
downward and forward translation of the maxilla
and simultaneous surface remodelling.
• Maxilla is like the platform on wheels being rolled
forward while at the same time, its surface,
represented by the wall in the cartoon, is being
reduced on its anterior surface and built up
posteriorly, moving in space opposite to the
direction of overall growth.

TRANSLATION
REMODELLING

Soft palate
• Ossification does not occur in the most
posterior part of the palate, giving rise to
the region of the soft palate.
• Myogenic mesenchymal tissue of first,
second and fourth branchial arches migrate
into the region supplying musculature of the
soft palate and fauces.

Control process and factors in facial
growth
VAN LIMBORGH’S CLASSIFICATION
Intrinsic genetic factors:Inherent in skeletal tissues
themselves.They exert influence inside the cell to which
they are inherent.
Local Epigenetic factors:Epigenesis includes the sum
total of all biochemical and biophysical events produced
by the functioning of the cells and organs ……Petrovic
General Epigenetic factors
Local environmental factors
General environmental factorswww.indiandentalacademy.com

LOCAL
Genetic control originating
from adjacent structure and provide
local actions
Example:Embryonic induction influences
sk. growth Brain,eye
GENERAL
Genetic control originating from distant
structure
and provide general actions
Example: Hormones
EPIGENETIC FACTORS

LOCAL
Non genetic influence evoked by
Stimuli originating from external
environment
Example:habits,forces of
musc.contraction
GENERAL
These are General non
genetic influences
Example:Nutrition,food,oxygen.
ENVIRONMENTAL
FACTORS

CONTROL MESSENGERS:
Growth control is essentially a localised developmental process
working with local function as it responds to multiple developmental
interplay with other growing parts.
FORCE/PRESSURE/TENSION
BIOPHYSICAL REACTIONS-Bone deformation,compression of
periodontal ligament,tissue injury
PRODUCTION OF FIRST MESSENGERS
Hormones[PTH],Prostaglandins,Neurotransmitters
PRODUCTION OF 2nd
MESSENGERS[Camp,Cgmp,Ca]
INCREASE IN CELLS OF RESORPTION/DEPOSITION

Paranasal Sinuses
Growth & Development of Air Sinus

Paranasal Sinuses
• Paranasal sinuses are bilaterally located intraosseous
chambers that are identified by the names of the bones in
which they are located. Hence they are known as:
1. Maxillary
2. Ethmoidal.
3. Frontal.
4. Sphenoidal.
The early paranasal sinuses expand into the cartilage walls
and roof of the nasal fossa by growth of mucous membrane
sacs (primary pneumatization) into the maxillary sphenoidal,
frontal and ethmoid bone. The sinuses enlarge into the bone
(secondary pneumatization) from their initial small
outpocketings always retaining communication with the nasal
fossa through ostia.

• Maxillary sinus: Develops at 10 weeks.
• Sphenoidal sinus. At 4 months i.u.
• Ethmoidal sinus. At 4 months i.u.
• Frontal sinus. 3 to 4 months.

Shape – Pyramid shape
Size of maxillary sinus:
• 32mm CRL of embryo  Starts developing
• 50mm CRL of embryo  1mm in diameter
• 160mm CRL of embryo  3.5mm
• 250mm CRL of embryo  7.5mm
Anteroposteriorly Superioinferiorly Mediolaterally
Perinatal period 7-16mm 2-13mm 1-7mm
1 year 15mm 6mm 5.5mm
15 years 31.5mm 19mm 19.5mm
Adult 34mm 33mm 23mm

• Microscopic features : lined by
pseudostratified columnar ciliated epithelium
• Functions:
1. Resonance of voice.
2. Lightening of the skull.
3. Production of bactericidal lyzozyme to the
nasal cavity.

Anomalies of Air Sinus
1. Agenesis.
2. Aplasia.
3. Hypoplasia.
4. Choanal atrisia.
5. Supernumerary maxillary sinus.

Anomalies of Maxilla
1. Epstein’s pearls and Bohn’s nodules
The entrapment of epithelial rests or pearls in the line of fusion
of the palatal shelves may give rise to median palatal rests
cysts.
2. Dental lamina cysts
Epithelial remnants of dental lamina that develop on the crest
of alveolar ridge.
3. Torus palatinus:
4. Oblique facial cleft
Failure of maxillary swelling to merge with its corresponding
lateral nasal swelling results in this deformity.
5. Cleft lip and palatewww.indiandentalacademy.com

6. Down syndrome (Trisomy 21): Flat face, large anterior
frontanelle, open sutures and prognathism, open mouth,
hypermobility, underdevelopment of sex, cardiac
abnormality, macroglossia, enamel hypoplasia.
7. Franschetti (Mandibulo facial dystosis) (treacher collins)
– hypoplasia of malar bones, mandible, macrostomia,
high palate, malformation of external ear, bird like or
fish like nature.
8. Marfan’s syndrome  Acrachnodactyly, spidery
fingers, hyper extensivity of joints, bifid uvula, high
arched palate, cardiovascular complications.www.indiandentalacademy.com

9. Cleidocranial dysplasia (Marie/Sainton’s
disease):
Frontenelle remain open, skull is flat and sagittal
suture is sunken, brachycephalic – complete /
partial, high, narrow arch palate, maxilla is
underdeveloped, absence of cellular cementum,
unerupted supernumerary teeth prevalent in
mandibular premolar and incisor, partial
anodontia.

10. Pierre robin syndrome (bird faces) – Cleft palate,
micrognathia, Glossoptosis.
11. Achondroplasia – Short, trachy cephalic skull, bowed
legs, lumbar lardosis, mandibular prognathism
(retrusion of maxilla).
12. Paget’s disease / ostetis deformans – Predominant in
above 40 yrs of age, bone pain, severe headache,
deafness, slight prediliction to men, progressive
enlargement of skull, waddling gait, maxilla exhibits
progressive enlargement – spacing between the teeth.
13. Crouzon’s / craniofacial dysplasias – Mandibular
prognathism, maxillary hypoplasia, high arched
palate, parrot’s beak like appearance, hypertelorism,
divergent strabismus.

Most common developmental anomaly is cleft
lip and cleft palate
• Cleft lip : Results from abnormal development
of the medial nasal process and maxillary
process.
• Cleft palate: Results from a failure of fusion
of two palatine process.

Classification of Cleft lip
I. Central
– Failure of fusion of two median nasal process.
II. Lateral
- Failure of fusion of maxillary process with medial nasal
process.
III. Complete / incomplete
Complete – Cleft lip extends to the floor of the nose.
Incomplete – Cleft does not extend upto the nostril.
IV. Simple or compound:
Simple : Cleft lip not involving alveolus.
Compound : Involving alveolus.

Classification of Cleft palate
• Veau (1931)
Group I - Cleft of the soft palate only.
Group II – Cleft of hard and soft palate.
Group III – Complete unilateral cleft
extending from uvula to incisive foramen
and then deviates to one side extending
through the alveolus.
Group IV – Complete bilateral alveolar cleft.

Internationally approved classification of cleft lip and cleft palate
A. Group 1: Cleft of the anterior (primary) palate.
a. Lip – Unilateral Rt/Lt – Total or partial
Bilateral
b. Alveolus – Unilateral Rt/Lt – Total or partial
Bilateral
B. Group II – Cleft of anterior and posterior (primary and secondary
palate)
a. Lip : Unilateral Rt/Lt – Total or partial
Bilateral
b. Alveolus : Alveolus – Unilateral Rt/Lt – Total or partial
Bilateral
c. Hard palate : Rt/ Lt Total or Partial.
C. Group III: Clefts of posterior (secondary) palate
• Hard palate Rt/ Lt.
• Soft palate
D. Group IV : Rare facial clefts.www.indiandentalacademy.com

Incidence:
• Cleft lip - 1:1000
• Cleft palate – 1: 2500

Problems associated with cleft palate
1. Interferes with swallowing.
2. Unable to make consonant sounds.
3. Upper lateral incisors, missing or absent.
4. Oral organism contaminate the upper
respiratory tract mucous membrane.
5. Hearing impairment.

Cleft lip and cleft palate repair
Cleft lip:
• Timing: Rule of TEN
Hb: >10gm%
Age : 10 weeks
Weight : >10lbs
TC: <10,000/mm3

Cleft lip alone
Unilateral - 5-6 months
Bilateral - 5-6 months
Cleft palate alone
Soft palate alone – 5-6 months
Soft and hard palate – Two operations
Soft palate – 6 months
Hard palate – 12-15 months
Cleft lip + Cleft palate:
Unilateral and Bilateral
2 stages of operation
1st
stage : Cleft lip + soft palate – 5-6 months
2nd
stage : Hard palate + gum pad + lip recision – 12-15
months

Prosthodontic Considerations
If it is decided the surgery will be unsuccessful for the
treatment of cleft soft palate then the first obturator is given at 2
years
• Cleft palate – Feeding plate is given immediately after birth.
Obturator is given later
Obturator
• Prosthesis is required for the patients who have undergone
tumor resection of hard palate and maxillary sinus.
Cleft palate –
• There are 3 types of obturators:
1. Surgical obturator.
2. Interim obturator.
3. Definitive obturator.

2. Cleft lip – Missing lateral incisors are replaced
with RPD or FPD or Implants.
3. Torus palatinus If Large – surgery
Small – relieve that area

9. Soft palate cleft – Artificial velum.
10. Oroantral fistula – Protective acrylic
denture or splint after immediate primary
closure to provide a barrier to the
inadvertent entry of food particles.
11. CA maxillary sinus – maxillectomy –
obturator.

Summary
• Maxilla develops from the 1st
pharyngeal arch
during 4th
week of i.u. life. Maxilla gives rise to
maxilla proper, premaxilla, zygomatic bone and
part of temporal bone.
• Growth changes are the result of downward and
forward translation of the maxilla and
simultaneous surface remodelling.
• Among the paranasal sinuses maxillary sinus is
the first sinus to develop at 10 weeks.

References
1. An introduction to human embryology for medical students –
Inderbir Singh, 5th
Edition.
2. Craniofacial embryology – G.H. Sperber, 4th
Edition.
3. Langman’s medical embryology – T.W. Sadler, 5th
Edition.
4. Colour atlas of clinical embryology – Keith L. Moore, T.V.N.
Persaud, 2nd
Edition.
5. Human anatomy, Regional and applied – Head, Neck and
Brain – B.D. Chaurasia, 3rd
Edition.
6. Orban’s oral histology and embryology – S.N. Bhaskar, 11th
Edition.

7. Oral histology, development, structure and function – A.R. Ten
Cate, 4th
Edition.
8. The essentials of facial growth – Enlow and Hans, 1st
Edition.
9. Contemporary Orthodontics – William R. Proffit.
10. Baily and Love’s - Short practice of surgery, 23rd
Edition.
11. Bouncher’s prosthodontic treatment for edentulous patients –
George A. Zarb, Charles L. Bolender, Judson C. Hickey,
Gunnar L. Carlsson, 10th
Edition.

Thank you

Growth and development of maxilla and maxillary /endodontic courses

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