Postnatal growth of face

1
Postnatal Growth of
facial Structure
Guide:
Prof. Dr. Situ Lal Shrestha
Department of Orthodontics and Dentofacial Orthopedics
Peoples Dental College and Hospital, Kathmandu, Nepal
Presented by:
Dr. Gaurav Acharya
PG Resident

2
Contents
1. Nasomaxillary Complex
2. Mandible
3. Facial Soft Tissue
4. Clinical Implications
5. Summary
6. References

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Nasomaxillary Complex Contd…
Composed of-
Paired maxillae
Nasal bones
Zygomatic bones
Lacrimal bones
Palatine bones
Ethmoid
Sphenoid
Vomer

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MAXILLA
Second largest bone of face
Two in number
Form:
→Whole upper jaw
→Roof of oral cavity
→Greater part of floor and lateral wall of nasal
cavity
→Part of bridge of nose.
→Greater part of floor of each orbit.

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Body
 Large and pyramidal in shape
 Base formed by nasal surface
 Apex directed towards
zygomatic process
Four processes
 Frontal
Alveolar
Zygomatic
Palatine

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Zygomatic process
Alveolar process
Frontal process

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Palatine process
Maxillary sinus
Frontal process
Alveolar process
Horizontal plate of palatine

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Development is via intramembranous
ossification except nasal septum
Growth occurs by:
1. Cranial Base Contribution
2. Growth at sutures
3. Surface remodeling
4. Nasal septum growth

9
Cranial base growth
pushes the maxilla
forward which occurs
up to 7 years
After that growth is at
the sutures
Spheno occipital Synchondrosis

10
Connected to the neurocranium by a
circummaxillary suture system

11
Intermaxillary suture
system composed of-
→Midpalatal
→Transpalatal
→Intermaxillary and
→Internasal sutures

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Growth of maxilla can be viewed in 3 aspects:
1.Growth in the Height
2.Growth in the transverse direction
3.Growth in the anterio-posterior
direction

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HEIGHT
Sutural growth toward frontal
and zygomatic bones
Appositional growth in-
• alveolar bone
• floor of orbit
• hard palate
Resorption on nasal floor

14

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Deposition on oral side.
Resorption on nasal side
Increases the height of
the nasal cavity

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Surface remodeling of bone in
the alveolar process
Increases the height of
palatal vault
Eruption of teeth

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Height of maxilla increased by displacement
process i.e. primary and secondary.
Primary displacement

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Primary displacement

19

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Secondary displacement

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TRANSVERSE DIRECTION
 Finished earlier in postnatal life.
 Occurs by two processes:
Alveolar remodeling in the
lateral surface of alveolar
process
Growth of the mid-
palatine suture

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ANTEROPOSTERIOR DIRECTION
Begins in the 2nd year of life
Ceases after increase in width has taken place.
Maxillary tuberosity Palatomaxillary suture

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ANTEROPOSTERIOR DIRECTION
Primary displacement Secondary displacement

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ANTEROPOSTERIOR
DIRECTION
 Resorption in the anterior
region of the maxilla
Amount of forward movement
of anterior surface is less than
amount of displacement

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Quantitation of maxillary remodeling. Sheldon
Baumrind, Edward Korn AJO JAN 1987
PNS, ANS & pt A
 Uniform displacement of all 3 pts in vertical direction
[downward displacement –0.3mm/year]
 Horizontally, displacement of PNS was greater than
ANS and pt A
Increase in length is primarily because of growth in
posterior border

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ORBITAL GROWTH
Follows Enlows V principle
 Endocranial side  Resorptive
 Orbital side Depository
Orbit is relocated anteriorly
 Bone deposition at various orbital sutures
Orbit are displaced out and away from each
other at same time

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Most of lining roof & floor
 depository
Lateral wall  deposition
Medial wall  resorpition

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NASAL FOSSA
Wall & floor of nasal
chamber  Resorptive
except nasal side of olfactory
fossa
Lateral and anterior
expansion of nasal fossa
Downward relocation of
palate

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Growth of SINUS
 Air filled cavity
 Pneumatization
of skeleton
 Humidification
of the inspired air
 Most sinus achieve adult size by 12 yrs
 Frontal sinus continue to enlarge till 20 yrs

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Maxillary Sinus
 Resorption except
mesial wall
 Rapid continuous
downward growth
 Close proximity to
buccal maxillary teeth

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SINUS
Postnatal Appearance of Sinus 1
1- OM Prakash Kharbanda. Orthodontics: Diagnosis and management of
Malocclusion and dentofacial deforminties

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Zygomatic Bone
Anterior surfacePosterior surface
ResorptionDeposition

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Bone deposition
Inferior edge of
the zygoma
Fronto-zygomatic
suture
Growth height of the
anterior part of zygomatic
arch
Increase in vertical
length of lateral
orbital rim

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Zygomatic Arch
 Resorption on the inner aspect
 Deposition on the lateral surface
 Enlarge temporal fossa
 Enlarge facial width

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Anterior Nasal Spine
 Prominence increase due to
bone deposition
 Resorption of labial cortex

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Nasal Septal Cartilage
Downward and forward
growth of the midface
At birth, nasal cavity is
between orbits
Nasal septal cartilage –
grows until age of 6
Lower the nasal cavity
below orbits.

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Nasal Septal Cartilage
Thrust and pull created
by nasal septal growth
separate the
frontomaxillary,
frontonasal,
frontozygomatic, &
zygomaticomaxillary
sutures

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Removal of
nasal septum
Mid face
deficiency

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Effect of removal of cartilaginous nasal septum in the rabbit.

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Functional matrix
hypothesis
Skeletal UnitFunctional Matrix
 Basal body Infraorbital nerve
 Orbital unit Eyeball
 Nasal unit Septal cartilage
 Alveolar unit Teeth

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Mandible
Largest amount of growth
post-natally
Largest variability in
morphology.
Developmentally and
functionally divisible into
several skeletal sub-units

44
Mandible Contd…
Moss describes the mandible as
a group of microskeletal units:
1. Coronoid process
2. Condylar process
3. Alveolar process
4. Angular / gonial process
5. Ramus
6. Body
7. Chin

45
Mandible Contd…
The mandible grows downward and forward by
Cartilaginous growth at the condyle
Bone remodelling
→Area relocation.
→Activity at surfaces determined by
regional directions of growth.
→Principle of the V

46
Mandible Contd…
At birth
Two rami of mandible are quite short
Condylar development is minimal
Thin line of fibrocartilage and connective
tissue exists at midline
Wide gonial angle
Between 4 months and 1 yr
Symphyseal cartilage is replaced by bone

47
Mandible Contd…
Birth – 6 months
Symmetric broadening downward and mainly
forward
During the 1st yr of life
Appositional growth is active at-
Alveolar border
Distal and superior surfaces of ramus, condyle
Lower border of mandible
Lateral surface of the mandible

48
Mandible Contd…
6 months – 4 years
Symmetric broadening posteriorly, downward
and forward
4 – 8 years
Broadening at condyles, downward and
forward
8 years onwards
Downward and forward

49
Mandible Contd…
CONDYLE
Important growth site
Covered by a thin layer of
cartilage called the Condylar
cartilage
Adaptation to withstand the
compression that occurs at the
joint

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Mandible Contd…
Earlier believed that-
Main growth center of mandibular growth
is the hyaline cartilage in its condyle
Condyle causes a downward and forward
shift of entire mandible

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Mandible Contd…
 In tissue culture and
transplantation experiments,
condylar cartilage was found
to be incapable of independent
growth
 But epiphyseal cartilage
produces a well organized
epiphyseal-metaphyseal unit

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Mandible Contd…
Result of experimental
condylectomy suggest that
the condyle may not make
an important contribution
to the spatial displacement
of the mandible

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Mandible Contd…
Current thinking is-
Condyles are not master center of growth
processes for other parts of the mandible
Growth of the other portions of the mandible
independent of condylar growth
Whole mandible can become displaced
anteriorly and inferiorly into its functional
position without a "push" against the
basicranium

54
Mandible Contd…
Growth of soft tissues, muscles, connective
tissue carries the mandible forwards away from
cranial base
Bone growth follows secondarily at the condyle
to maintain constant contact with the cranial
base.

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Mandible Contd…
Lingual and buccal
sides of the neck have
resorptive surfaces
Neck relocated into
areas previously held
by the much wider
condyles

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Mandible Contd…
RAMUS
Remodelling of ramus -
1) Positions lower arch in occlusion with the upper
2) Facilitate lengthening of the mandibular body
3) Accommodates erupting molars

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Mandible Contd…
Resorption  Anterior Part
Deposition Posterior region
Drift of ramus in a posterior
direction.

58
Mandible Contd…
Greater amounts of
bone additions on
the inferior part
Uprighting of Ramus
Greater amount of
resorption inferiorly
than superiorly

59
Mandible Contd…
CORPUS/ BODY OF
MANDIBLE
Ramus remodelling
Displacement of the ramus
Ramal bone relocates into
posterior part of body of the
mandible.
Lengthening of body of
mandible

60
Mandible Contd…
Angle of the mandible
Lingual side 
→resorption on posterio-inferior aspect
→deposition on antero-superior aspect
Buccal side
→resorption on antero-superior part
→deposition on postero-inferior part

61
Mandible Contd…
Gonial Angle
Obtuse (140° or more) in
infants
About 110° in adults
Closes with growth to
prevent change in the
occlusal relationship between
the upper and lower arches

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Mandible Contd…
Anti- gonial notch
Single field of surface
resorption present on
inferior edge of mandible
At the ramus corpus
junction

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Mandible Contd…
Anti- gonial notch
Growth of the mandibular
condyle fails to lower mandible
Masseter and medial pterygoid
growth cause the bone in the
region of angle to grow
downward
Produce Antegonial notching.

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Mandible Contd…
Antegonial notch determined by:
Gonial angle
Extent of bone deposition on just posterior or
anterior to the notch.
Less prominent gonial angle closed
More prominent gonial angle opened

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Mandible Contd…
Singer and Hunter (AJO 1987)
Evaluatation of depth of antegonial notch as an
indicator of mandibular growth potential
Deep notch 
Diminished mandibular growth potential
Vertically directed mandibular growth pattern
Required a longer duration of orthodontic
treatment than shallow notch patients.

66
Mandible Contd…
Chin
Specific human characteristic
Found in its fully developed form in
recent man only.
Most stable area within the outline of
the mandible
Deposition on the anterioinferior
surface
Resorption in anteriosuperiorly

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Mandible Contd…
Chin
Underdeveloped in infant
 As age advances growth of the
chin becomes significant.
Influenced by sexual and specific
genetic factors
Males have prominent chins as
compared to females.

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Mandible Contd…
Alveolar Process
Controlled by dental eruption
Resorbs when teeth are exfoliated or
extracted.
Serves as a “buffer zone”  maintain
occlusal relationships during differential
mandibular and midface growth

69
Mandible Contd…
Growth persists even after corpus growth is over
Compensate for the occlusal surfaces wear of
teeth
Maintain occlusal height in adulthood
Adaptive remodeling makes orthodontic
movements possible.

70
Mandible Contd…
CORONOID PROCESS
Enlarging V principle, with the
V oriented vertically
Lingual side faces three general
directions all at once:
posteriorly, superiorly, and
medially

71
Mandible Contd…
Rotation of mandible during growth

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Mandible Contd…
Rotation of mandible during growth
Internal Rotation – occurs in the
core of each jaw.
External Rotation – produced by
the surface changes and alterations
in the rate of tooth eruption that
mask the internal rotation.
Change orientation of mandible, as
determined by mandibular
plane

73
Mandible Contd…
Forward rotation
When anterior vertical growth > posterior
growth
Compensatory remodelling

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Mandible Contd…
Backward rotation
When posterior vertical growth > anterior
growth
Compensatory remodelling

75
Facial Soft tissue
Lips
 Growth of soft tissue is not parallel to underlying
hard tissue
 Growth of lip lag behind growth of facial skeleton
until puberty
11 14 18

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Facial Soft tissue Contd…

77

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Nose
 Nasal bone growth completes at age 10
 After 10, growth of cartilaginous & soft tissue.
10 12

79
14 17

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Clinical Implications
Trauma
Effects on skeletal growth are not so much
caused by the trauma itself as by the resulting
scarring within the soft tissues that restricts
further growth

81
Clinical Implications Contd…
 Pronounced forward rotation of mandible
Risk of deep bite
 Prevented by
Stabilizing appliance, such as bite plane,
introduced before puberty

82
 In case of backward rotation
Opening of the bite
 Difficult to prevent
 Postpone treatment until pubertal growth spurt is
nearly over.

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At birth
Hard palate : length = width
Maxillary sinus : not visible radiographically
1 – 2 years
Extensive remodeling descent of
palate /enlargement of nasal cavity

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Aging Changes in Soft tissue

85

86

87

88

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References
William R Proffit, Henry Fields, David M
Server; Contemporary Orthodontics, 5th
edition
Graber, Vanarsdall, Vig; Orthodontics -
Current principles and Techniques
Enlow & Hans- Essential of facial growth, 1st
edition

91
References
G.H.Sperber, Craniofacial Development
OM Prakash Kharbanda. Orthodontics:
Diagnosis and management of Malocclusion
and dentofacial deforminties
Sameer E Bisara, Textbook of orthodontics,
W.B.Saunders Company
Singer and Hunter. Evaluatation of depth of
antegonial notch as an indicator of mandibular
growth potential. AJO 1987

92
References
Steve Galella, Daniel Chow, Jones; Guiding
Atypical Facial Growth Back to Normal; IJO,
vol 22, 2011
Sheldon Baumrind, Edward L et al.
Quanttitation of maxillary remodeling. AJODO
June 1987
Thomos Rakosi. Color atlas of Dental Medicine
Netters Atlas of Human Anatomy.

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