Pre Natal and Post Natal / orthodontic courses by Indian dental academy

Pre natal and post natal growth and development of nasomaxillary complex

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

Growth and development of Nasomaxillary complexAnatomyPre natal growth Post natal growthClinical implications

ANATOMY OF MAXILLA Two maxillae articulate to form

– 1. Whole upper jaw.– 2. Roof of oral cavity.– 3. Greater part of floor and

lateral wall of nasal cavity and part of nasal bridge.

– 4. Greater part of floor of each orbit.

ANATOMY OF MAXILLA. PARTS OF MAXILLA.

– 1. BODY –LARGE AND PYRAMIDAL IN SHAPE.

– 2. FOUR PROCESSES. FRONTALZYGOMATICALVEOLAR

PALATINE

MAXILLA HOUSES THE LARGEST SINUS OF THE FACE THE MAXILLARY SINUS

Palatine process[maxilla]

Maxillary sinus

Frontal process

Maxillary process [palatine]

Alveolar process

ANATOMY – MEDIAL VIEW

Horizontal plate of palatine

Nasal notch

Zygomatic process

Alveolar process

ANATOMY-LATERAL VIEW

Frontal process

Pre natal growth and development

Pre-natal growth At fourth week of of IUL- 1.migration of neural crest cells 2.formation of brachial arches

STOMODEUM

FRONTONASAL

MAXILLARYMAXILLARY

MANDIBULAR MANDIBULARwww.indiandentalacademy.com

Medial nasal process

Lateral nasal process

Maxillary process

Mandibular process

Maxillary and Mandibular processes- { first brachial arch} Frontonasal processes- { downward

proliferation of mesenchyme of developing brain}

Medial nasal Lateral nasal

Mesenchyme of first arch

maxilla

palatine

mandible

zygomatic

Part of temporalwww.indiandentalacademy.com

AT SEVENTH WEEK IUL- 1.Formation of upper lip 2.Intramembranous Bone

ossification Takes Place 3.Formation of Nasal Septum 4.Nasolacrimal Duct 5.Formation of Primary Palate

AT SEVENTH WEEK IUL Primary ossification center -for each

maxilla at termination of infraorbital nerve above canine tooth dental lamina.

Secondary center zygomatic

orbitonasal

intermaxillarynasopalatine

AT EIGHT WEEK IUL Intramembranous ossification centers

appear for;-Nasal and lacrimal bones.-Medial pterygoid plate of sphenoid.-Vomer.-Zygomatic bone

Anteroposterior maxillo- mandibular relationship approaches that of newborn infant

Maxilla increases in height

BY TWELFTH WEEK

FRIEBAND-{the growth of palate in human fetus}

1st trimester-narrow 2st trimester-moderate width 3st trimester- wide Breadth>length Height changes less dramatic

Pre-natal Growth and development of palate

Formation of primary and secondary palate

Elevation of palatal shelves

Fusion of palatal shelves

Early palate formation

28th day of IUL -disintegration of buccopharangeal

membrane -stomadeal chamber

Horizontal extensions

Oral cavity

Nasal cavity

2 palatal shelves

Single primary palate

Structure of palate

PALATOGENESIS

Secondary palatePrimary palate

5 TH week IUL 12 TH week IUL6 9

CRITICAL PERIODwww.indiandentalacademy.com

Primary palateFrontonasal process

Medial nasal

mesenchyme

Wedge shaped mass between internal surface of maxillary prominence

Primary palatePre-maxilla

Primary palate

Secondary palate

2 horizontal mesenchymal projections

Maxillary prominence

Lateral palatine process

Fuse-With each otherPrimary palate

Nasal septum

Secondary palatewww.indiandentalacademy.com

Secondary palate

PALATAL SHELVES

Elevation of palatal shelves At 6 weeks1. Tongue {undifferentiated tissue} pushes dorsally2. palatal shelves become vertical3. Elevation occurs from vertical to

horizontal position

Elevation of palate

Nasal septum

Palatal shelves

tongue

Histological section

At 8 weeks

Elevation of palatal shelves

Muscular movement

Pressure differences

Biomechanical transformation

Intrinsic shelf force Differential

mitotic growthWithdrawal of embryo’s face

Fusion of palatal shelves

Fusion of the palatal shelves

In the closest union there is still some separate existence of component parts ; in the most complete separation there is some reminiscence of union Samuel Butler

Fusion of palate

Incisive foramen

Mid palatine raphe

Formation of palate[summary]Primordium of

Formed by

Derived from

Primary palate

Secondary palate

Pre maxilla

Hard and soft palate

Median palatine process

Lateral palatine process

Frontonasal process

Maxillary process

Musculature of palate

Tensor veli palatini 40 days 1st arch Palatopharangeous 45 days Levator veli palatini 8th week 2nd arch Palatoglossus 9th week Uvular muscle 11th week 2nd arch

Growth in dimensions

Length - 7-8 weeks IUL Width - 4th month onwards

heightwidthlength

Arched palate

Growth in dimensions

Pre natal life length > width

At birth length = width

Post natal life width > length

Growth at mid palatal suture ceases at 1-2 years

Apposition inferior surface alveolar process Resorption –superior{nasal} surface

V principle of Bang and Enlow

Entire ‘v’ shaped structure moves in a direction towards the wide end of the ‘v’

Remodeling of palate

Factors affecting growth of palate

elevation of head and lower jaw Oxygen and nutritional deficiency Excess endocrine substances Drugs Irradiation vascularity

teratogens

Elevation of head and lower jaw

ANOMALIES OF PALATE Epithelial pearls

ANOMALIES OF PALATE

Torus palatinus

ANOMALIES OF THE PALATE

High arched palate

MARFANS SYNDROME

CROUZON SYNDROME

CLEIDOCRANIAL DYSOSTOSIS

ANOMALIES OF PALATE

Cleft palate

Failure of fusion of the lateral palatine process with each other or with the median palatine process

Genesis of cleft palate Delay in shelf elevation Disturbance in mechanism of shelf

elevation Failure of shelves to contact due to lack

of growth Failure to displace the tongue during

closure [Pierre Robin syndrome]

Genesis of cleft palate

Failure to fuse after contact as epithelium does not break down

Rupture after fusion

defective merging

Types of cleft palate

Bifid uvulaUnilateral cleft palate

Bilateral cleft palate

Bifid uvula

Unilateral cleft palate

Etiology of cleft palate

Infectious agents

irradiation drugs

Nutritional deficiency

Excess hormones

Smoking and alcohol

Clinical features of cleft palate Feeding problems particularly in infants

in whom suckling process demands intact palate

Nasal regurgitation/nasal twang in voice

Collapsed arch

Difficulty in speech and swallowing

Post natal growth of maxilla

Surface remodeling

displacement

CRANIAL BASE MAXILLA

apposition resorption

TRANSPOSITION

TRANSLATION

SUTURES

Surface apposition Sutural growth nasal septum growth Spheno occipital synchondrosis

In contrast to cranial base maxilla is dominated by intra membranous ossification

Surface apposition

Sutural growth

Spheno occipital synchondroses

Growth in height vertical

Growth in width transverse

Growth in length A - P

HEIGHT

DEPOSITION ON THE ORAL SIDE

RESORPTION ON THE NASAL SIDE

ENLOW AND BANG ‘V’ PRINCIPLE

Sagittal view Coronal view

HEIGHT - ‘V’ PRINCIPLE

HEIGHT

APPOSITION IN THE ALVEOLAR PROCESS

ERUPTION OF TEETHwww.indiandentalacademy.com

Primary displacement

HEIGHT

PRIMARY DISPLACEMENT

SUTURAL THEORY

CARTILAGENOUS THEORY

FUNCTIONAL MATRIX HYPOTHESIS

SUTURAL THEORY

SUTURES HAVE INNATE GROWTH POTENTIAL

OBLIQUE NATURE

SLIDING EFFECT

SICHER

CARTILAGENOUS THEORY

NASAL SEPTUM –INNATE GROWTH POTENTIAL

THRUST EFFECT– SEPTOPREMAXILLARY LIGAMENT

MORE ROLE IN A-P THAN VERTICAL

SURGICAL REMOVAL OF NASAL SEPTUM

Removal of nasal septum –mid face deficiency

BASAL BODY INFRAORBITAL

ORBITAL UNIT EYEBALL

NASAL UNIT SEPTAL CARTILAGE

ALVEOLAR UNIT TEETH

SKELETAL UNITS FUNCTIONAL MATRIX

HEIGHT

ENLARGING ORO FACIAL CAPSULE

REMODELING CHANGES IN THE ORBIT

WIDTH Finished earlier in postnatal life

WIDTH GROWTH IN MID PALATINE SUTURE

REMODELING IN THE LATERAL SURFACE OF ALVEOLAR PROCESS

Mutual transverse rotations of maxillary halves give palate ‘u’ shape

LENGTH Begins rapidly in the 2 nd year of life

Maxillary tuberosity

Palato -

maxillary suture

primary secondary

displacementwww.indiandentalacademy.com

QUANTITATION OF MAXILLARY REMODELING

Uniform displacement of all 3 pts in vertical direction [downward displacement –0.3mm/year]

Horizontal direction posterior displacement of all 3 pts [however the displacement of PNS was greater than ANS and pt A ]

THE INCREASE IN LENGTH IS PRIMARILY BECAUSE OF GROWTH IN POSTERIOR BORDER

Sheldon Baumrind,Edward Korn

AJO JAN 1987

Maxillary tuberosity Established by the posterior boundary

of anterior cranial fossa Helps in posterior and horizontal

lengthening of arch

Anterior displacement

= posterior lengthening

Key ridge

Reversal occurs at the key ridge

Posterior - apposition

Anterior - resorption

Maxillary sinus PRE NATAL lateral evagination of mucous

membrane in middle meatus –3rd month IUL

AT BIRTH 2mm -long, 1mm in width + height PNEUMATISATION

PRIMARY SECONDARYwww.indiandentalacademy.com

Maxillary sinus

AGE CHANGES

Expands - 2mm vertically 3mm A-P - every year

> in size - resorption in walls + alveolus

Maxillary sinus

POST NATAL All internal surfaces

resorption[expect medial]

Rapid continues downward growth

close proximity to buccal maxillary teeth

Zygomatic region

Posterior relocation

anterior posterior

Increase in height

frontozygomatic Inferior border

Lateral growth

displacementZygomaticotemporal [anterior]

Frontozygomatic [inferior]www.indiandentalacademy.com

Nasal airway

Lining surface of bony wall and floor resorptive

Downward relocation of palate

Lateral and anterior expansion

Nasal airway Ethmoidal

conchae lateral + inferior

depositionmedial + superior

resorption

Inter nasal septum

Lengthens vertically at sutural junctions

Clinical Implications and Summary

Pre natal growth

Formation of germ layers

Day 17 Fetal alcohol syndrome

[mid face deficiency]

Migration and proliferation of cell population

Day 19-28Treacher Collin syndrome

Pre natal growth

Primary palate formation

28-38 days

Cleft lip /cleft palate other facial clefts

Secondary palate formation

42-55 days

Cleft palate/synostosis

CROUZON syndrome

Epithelial pearls

Torus palatinus

high arched palatewww.indiandentalacademy.com

Post natal growth

Post natal growth AT BIRTH

Hard palate : length = width

maxillary sinus : not visible radiographically

1 – 2 years

Extensive remodeling descent of palate /enlargement of nasal cavity

Mid palatine suture growth ceases

No synostosiswww.indiandentalacademy.com

Post natal growthTHE MIXED DENTITION YEARS

Post natal growth

mid palatine suture starts closing at 9- 10 years

RME BEST DONE BETWEEN 9-14 yrs

THE MIXED DENTITION YEARS

Growth in width of the dental arch anterior to the first molar

Ceases by 5-6 yrs

Inter canine width completed

12 yrs - females

18 yrs - males

Post natal growth

THE DEPOSITORY GROWTH POTENTIAL OF TUBEROSITY ALLOWS FOR ARCH EXPANSION BY MOVING THE TEETH POSTERIORLY INTO THE AREA OF BONE DEPOSITION

EXTENSIVE SCOPE FOR GROWTH

MODIFICATION BEFORE ADOLESCENT GROWTH SPURT

THE MIXED DENTITION YEARS

Post Natal Growth THE EARLY PERMANENT DENTITION YEARS

•Growth modification still possible in boys

•RME can still be tried till 12 -15 yrs

•>15 years complete closure[synostosis]

Orthognatic surgerywww.indiandentalacademy.com

Age changes All para nasal sinuses increase in size Vertical height decreases

Vertical changes > AP > width Soft tissue changes > skeletal Nose growth continues till 25 years Inclination of palatal plane

increases[post downwards]

Alveolar process resorbed

Tooth loss

References Contemporary orthodontics- PROFFIT Principles and practice of orthodontics –

GRABER Essentials of facial growth- ENLOW Craniofacial embryology- SPERBER The developing human-KEITH MOORE oral histology and embryology-

TENCATE Handbook of orthodontics-MOYERS

References quantitation of maxillary remodeling-S

BAUMRIND ,E KORN –AJO JAN 97 Dentistry for child and adolescent-MAC

DONALD Clinical pedodontics-FINN Color atlas of Embryology

MOORE,PERSUAD Clinical oral pathology-

NEWILLE ,WHITE Diseases of oral mucosa-

BORK,HOEDEwww.indiandentalacademy.com

Thank you

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