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

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
www.indiandentalacademy.com


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

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

Area of Nasomaxillary Complex


Anatomy
Skelet al Tissues / Bones
• Maxilla
• Zygomat ic
• Palat ine
• Lacr imal
• Vomer
• Nasal spine, sept um
• Et hmoid
• Sphenoid


Sinuses
•
•
•
•
•

Anatomy

Maxillar y
Fr ont al
Et hmoid
Sphenoid
Nasal cavit y

 Radiological

appear ance


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

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

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

Maxilla – Medial View
Frontal process

Maxillary sinus
Maxillary process [palatine]
Horizontal plate of palatine
Palatine process[maxilla]
Alveolar process

Maxilla - Lateral View
Frontal process

Nasal notch
Zygomatic process
ANS
Alveolar process


Maxilla


Anatomy Of Maxilla


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


Anatomy Of Maxilla

At bir t h

Adult


Palatine bone


Palatine Bone
Hor izont al plat e
Per pendicular plat e
Pyr amidal pr ocess
Or bit al pr ocess
Sphenoidal pr ocess


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

Zygomatic Bone


Lacrimal Bone
Smallest – most f r agile
Ar t iculat es wit h
Maxilla
Fr ont al bone
Et hmoid
bone
Nasal concha

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.

Vomer
Tr apezoid
Post er ior par t of nasal
sept um


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

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

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.

External nose


Para nasal Sinuses
Maxillar y sinus
Fr ont al sinus
Et hmoidal sinus
Sphenoidal sinus


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,
www.indiandentalacademy.com is t he ostium
maxillare, or opening f r om t he

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 www.indiandentalacademy.com
ull size af t er puber t y

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

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

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

Radiological appearance


Indices
•
•
•
•
•
•
•

Cephalic index
Tot al f acial index
Upper f acial index
Nasal index
Or bit al index
Palat al index
Gnat hic index


Para nasal Sinuses


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

Muscle attachments


Blood vessels, Nerves &
Lymphatics

External carotid artery
V & VII cranial nerve
Submandibular lymphnodes


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

Development of Embryo
•

1st week – 3 rd week

•

Ovum

Zygot e

Blast ocyst

Gast r ula

Neur ulat ion


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

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

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

•
•
•







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

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

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

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

Branchial Arches
 Sixth

arch
• Cricoid cartilage
arytenoid cartilage
• R
ecurrent laryngeal nerve


P natal growth and
re
development


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

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


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

Medial nasal
process

Lateral nasal process
Maxillary process
Mandibular process


 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


Nasal process

Lat er al
nasal
pr ocess

Median nasal
pr ocess


 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


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


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 www.indiandentalacademy.com

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


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

Growth of palate
•

Two pr imor dia, pr imar y palat e and
secondar y palat e


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

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

 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

Primary palate
Frontonasal
process

Medial nasal

Mesenchyme

P maxilla
re-

Wedge shaped
mass between
P
rimary palate
internal surf ace
www.indiandentalacademy.com maxillary
of

Primary palate
Pr i m y
ar
pal at e


Secondary palate
Maxillary prominence

2 horizontal mesenchymal projecti
Lateral palatine process
Fuse-

With each
other
P
rimary
palate
Nasal septum

Secondary
palate

Secondary palate

Palat al Shelves

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



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

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

Elevation of head and
lower jaw


Fusion of palatal shelves


Fusion of palate
Incisive f oramen

Mid palatine
raphe


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

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

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

Growth in dimensions
height
width
length

 Lengt h
 Widt h

Arched
palate

- 7-8 weeks I UL
- 4 t h mont h onwar ds

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

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

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


Neonatal Skull


Clef t Lip and P
alate


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

Inf ectio
us
agents

Irradiation

Drugs

Etiology of clef t lip /
palate
Nutritional
def iciency

Excess
hormones

Smoking
and
alcohol

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
•


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


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

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

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

ANOMALIES OF P
ALATE
 Epit helial

pear ls


ANOMALIES OF P
ALATE
 Tor us

palat inus


ANOMALIES OF THE P
ALATE

High ar ched palat e

MAR
FANS
SYNDR
OME

CR
OUZON
SYNDR
OME

CLEIDOCR
ANIAL
DYSOSTOSIS


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]

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

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

Types of clef t palate

B id
if
uvula

Unilateral
clef t
palate

B
ilateral
clef t
palate

Unilateral clef t
palate

B
ilateral
clef t
palate
B id uvula
if


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

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,

•
•

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

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

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.

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 www.indiandentalacademy.com

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

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
•


Cheiloplast y
• Rule of Tens
10 weeks of age
10 pounds of body weight
10 gr ams of hemoglobin
•


•

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


 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

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

•
•
•
•


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

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

P
ost natal growth of
Nasomaxillary complex


•
•

•

•

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

Displacement
•

Pr imar y
displacement

•

Secondar y
displacement


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

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

 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


•

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


Surface apposition


Spheno occipital synchondroses


Post natal growth


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

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

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

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

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]

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


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

 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

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


HEIGHT
ENLOW AND BANG ‘V’
PRINCIPLE


Deposition on the
oral side



R
esorption on the
nasal side


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’


H EIGHT

AP OSITION IN
P
THE ALVEOLAR
P OCESS
R
ER TION OF TEETH
UP


HEIGHT

-

V’ PRINCIPLE

Sagi t t al www.indiandentalacademy.com
Cor onal

HEIGHT
P
rimary displacement


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

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

LENGTH
 Begins

r apidly in t he 2 nd year of lif e

Maxillary P
alato
primary secondary
tuberosity maxillary
suture
displacement

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
•


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
•


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

Theor ies of gr owt h
 SUTURAL
 CARTI

THEORY

LAGENOUS THEORY

 FUNCTI

ONAL MATRI X HYPOTHESI S

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


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
•

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 ofwww.indiandentalacademy.com
Nasal sept um…



Removal of nasal sept um –mid f ace
def iciency


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

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

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

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. www.indiandentalacademy.com

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

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

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


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

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
•


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

Nasal air way


Ethmoidal conchae
- lateral + inf erior
deposition
- medial + superior
resorption



Inter nasal septum
- lengthens
vertically at sutural
junctions

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
•


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


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

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


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

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 ]


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

Maxillar y sinus
P
OST NATAL
 All internal
surf aces
resorption
[expect medial]


R
apid continuous
downward growth
close proximity to
buccal maxillary
teeth



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

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

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.

Ability is what you’re capable of doing.
Motivation determines what you do.
Attitude determines how well you do it.
- Lou Holtz

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

Thank you
For more details please visit


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

More Related Content

What's hot (20)

Viewers also liked (20)

Similar to Development of naso maxillary complex /certified fixed orthodontic courses by Indian dental academy (20)

More from Indian dental academy (20)

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