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By: Rajsandeep Singh 1st year PG- Prosthodontics Guided by: Dr.

Nidhi Duggal

The

study of the development of the face and oral cavity is of particular interest to the prosthodontist as it helps to improve the understanding of the form and function of the stomatognathic system. Also it helps in understanding the genesis of various developmental defects which is important while treating them.

The

development begins with the fertilization of the ovum which usually occurs in the ampullary part of the fallopian tube. Before we jump to the development of the face let us first briefly go through the changes occurring in the beginning of the pre-embryonic period.

The

period of the zygote is from fertilization to 3rd week From 3rd week to 8th week is the period of the embryo. 8th week onwards the fetal period starts.

a)

b)

c) d)

Zygote divides to reach the 2 cell stage. With another set of divisions the no. of cells reaches 4. the cells become smaller and form a loosely arranged clump. With the third cleavage the cells become compact Approx. 3 days after fertilization the cells form a 16 celled morula with an outer cell layer and an outer layer with the inner layer forming the embryo proper and the outer one forming the placenta.

About the time the morula enters the uterine cavity, fluid begins to penetrate through the zona pellucida into the intercellular spaces of the inner cell mass. Gradually, the intercellular spaces
become confluent, and finally, a single cavity, the blastocele. At this time, the embryo is a blastocyst. Cells of the inner cell mass, now called the embryoblast, are at one pole, and those of the outer cell mass, or trophoblast, flatten and form the epithelial wall of the blastocyst.

Trophoblats differentiate into syncytiotrophoblasts and cytotrophoblasts

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At 9th day, blastocyst completely embedded into endometrial wall At days 11 and 12, the syncytiotrophoblasts erode into endometrial blood vessels to establish uteroplacental circulation By end of 2nd week, secondary yolk sac is formed and amniotic cavity appears At this time, a bilaminar embryonic disc forms consisting of the epiblast and the hypoblast.

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Formation of trilaminar disc ocuurs at week 3.(gastrulation) The 3-layered disc consisiting of ectoderm, mesoderm and endoderm is known as the gastrula. It begins with formation of primitive streak. The cells of the epiblast proliferate and upon arrival at the streak they become flask shaped and slip beneath the epiblast causing an invagination. This invaginaion displaces the hypoblast creating the endoderm. The cells in between form the mesoderm and remaining cells of the epiblast form the ectoderm.

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3. 4.

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Prenotochordal cells invaginating the primitive pit move forward cephalically until they reach the prechordal plate region where they intercalate with the hypoblast cells. Thus for a short time midline of the embryo consists of 2 layers which form the notochordal plate. As the hypoblast is replaced by the endoderm these cells detach from the endoderm forming a solid cord of cells- the definitive notochord which underlies the neural tube giving basis for the axial skeleton (including the head and neck)

The neural tube develops in two ways: primary neurulation and secondary neurulation. Primary neurulation divides the ectoderm into three cell types: The internally located neural tube The externally located epidermis The neural crest cells, which develop in the region between the neural tube and epidermis but then migrate to new locations

In secondary neurulation, the cells of the neural plate form a cord-like structure that migrates inside the embryo and hollows to form the tube.

With development and growth of the brain vesicles the embryonic disc begins to bulge into the amniotic cavity and fold cepahalocaudally forming the head and tail folds. As a result of cephalocaudal folding, a continuously larger portion of he endoderm-lined cavity is incorporated into the body of the embryo proper giving rise to foregut anteriorly and hindgut posteriorly. At cepahlic end the foregut temporarily comes in contact with the endoderm forming the buccopharyngeal membrane.

The

head and neck region of the fourth week human embryo somewhat resembles these regions of a fish embryo of comparable stage explains the former use of designation branchial apparatus is derived from the Greek word branchia or gill

This

Branchial

Pharyngeal apparatus consists of:


Pharyngeal

arches Pharyngeal pouches Pharyngeal grooves Pharyngeal membrane

Muscle Mastication muscles (temporal, masseter, medial and lateral pterygoids), mylohyoid, anterior belly of the digastric, tensor veli palatini, tensor tympani Bone and cartilage Mandible, maxilla, premaxilla, zygomatic bone, squamous part of the temporal bone, pinna of the ear (anterior), Meckel's cartilage (malleus, incus) Other connective tissue Anterior ligament of the malleus, sphenomandibular ligament Pouch derivatives Middle ear cavity, auditory (Eustachian) tube, tympanic membrane Cleft derivatives External auditory meatus Nerve supply V (trigeminal nerve)

Muscle Facial expression muscles, stapedius, stylohyoid, posterior belly of the digastric Bone and cartilage Reichert's cartilage (stapes, styloid process), hyoid bone (lesser horn and upper body), pinna of the ear (posterior) Other connective tissue Stylohyoid ligament Pouch derivatives Palatine tonsils Cleft derivatives The 2nd arch grows to cover the remaining clefts failing which a branchial cyst develops Nerve supply VII (facial nerve)

Muscle Stylopharyngeus Bone and cartilage Hyoid bone (greater horn and lower part of the body) Other connective tissue None Pouch derivatives Inferior parathyroid, thymus Cleft derivatives none Nerve supply IX (glossopharyngeal nerve)

Muscle Cricothyroid, levator velum palatini, constrictors of pharynx, intrinsic muscles of the larynx Bone and cartilage Laryngeal cartilages (cricoid, thyroid, arytenoid, corniculate, cuneiforme) Other connective tissue None Pouch derivatives Superior parathyroid, ultimobranchial bodies of the thyroid Cleft derivatives None Nerve supply X (superior and recurrent laryngeal branch of the vagus nerve)

The

facial primordia appear early in the fourth week around the primordial stomodeum

FN
MX md MX md

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Mesenchyme for the formation of head and neck is derived from paraxial and lateral plate mesoderm, neural crest, and thickened regions of the ectoderm called ectodermal placodes.

Paraxial

mesoderm (somites and somitomeres) form the voluntary muscles of the craniofacial region. These are supplied by the somatic efferent nerve fibers. Lateral plate mesoderm forms the laryngeal cartlilages and the connective tissue in this region.

Neural crest cells originate in the neuroectoderm of forebrain, midbrain, and hindbrain regions and migrate ventrally into the pharyngeal arches and rostrally around the forebrain and optic cup into the facial region. In these locations,they form the entire viscerocranium (face) and parts of the membranous and cartilaginous regions of the neurocranium (skull) They also form all other tissues in these regions, including cartilage, bone, dentin, tendon, dermis, pia and arachnoid, sensory neurons, and glandular connective tissue.

Cells

from ectodermal placodes, together with neural crest, form neurons of the fifth, seventh, ninth, and tenth cranial sensory ganglia.

The

Nasal placodes:

Two bilateral oval thickenings in the surface ectoderm, of the frontonasal prominence, appear, by the end of the fourth week.

Nasal placodes are the primordia of the nose and nasal cavities. Initially these placodes are convex. Later, they are stretched to produce a flat depression in each placode.

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As the neural tissues grow they cause the pericardial bulge to come close to the developing stomodeum. During the third week of embryonic development, two areas of thickened ectoderm, the olfactory areas, appear immediately under the fore-brain in the anterior wall of the stomodeum, one on either side of a region termed the frontonasal prominence (or process) which is formed by the bulging of the developing forebrain. By the upgrowth of the surrounding parts these areas are converted into pits, the olfactory pits, which indent the frontonasal prominence and divide it into a medial and two lateral nasal processes.

The

maxillary process develops from the dorsal portion of the 1st pharyngeal arch which extends forward beneath the region of the eye. The ventral portion forms the mandibular process which contains the Meckels cartilage.

Five facial primordia appear as prominences around the stomodeum


FNP

The

single frontonasal prominence paired maxillary prominences

The

The

paired mandibular prominences


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The

paired facial prominences are derivatives of the first pair of pharyngeal arches The prominences are produced mainly by the proliferation of neural crest cells.

These cells migrate from the Mesencephalon and & Rhombencephalon regions of the neural folds into the arches during the fourth

1st

week
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The

lower jaw and lower lips are the first parts of the face to form
result from merging of the medial ends of the mandibular prominences in the median plane cleft lower lip is a very rare condition
M
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They

Median

Each lateral nasal prominence is separated from the maxillary prominence by a cleft called nasolacrimal groove

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The

nasolacrimal duct develops from a rodlike thickening of ectoderm in the floor of the nasolacrimal groove
thickening gives rise to a solid epithelial cord that separates from the ectoderm and sinks into the mesenchyme a result of cell degeneration, this epithelial cord canalizes to form the nasolacrimal duct
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This

As

The cranial end of this duct expands to form the lacrimal sac By the late fetal period, the nasolacrimal duct drains into the inferior meatus in the lateral wall of the nasal cavity The duct usually becomes completely patent only after birth Occasionally, part of the duct fails to canalize causing atresia of the nasolacrimal duct.

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By the end of the fifth week, the primordia of the auricles of the ears have begun to develop Six auricular hillocks form around the first pharyngeal groove (cleft). Three on each side of the 1st pharyngeal groove (cleft). These are the primordia of the auricle and external acoustic meatus.

Initially the ear located in the neck. As the mandible develops the ears ascend to the level of the eye.

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Development of The Palate


As the medial nasal prominences merge, they form an intermaxillary segment
The intermaxillary segment gives rise to: 1- The Philtrum (median part of the upper lip). 2- The Premaxillary part of the maxilla and associated gingiva (gum). 3- The primary palate.

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The palate develops from two stages:


Primary

palate Secondary palate


Palatogenesis

begins at the end of the fifth week and is completed at twelfth week (5------12 )

The critical period of the palate development is from the end of the sixth week until the beginning of ninth week (6 ------ 9)
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Early

in the sixth week the primary palate or median palatine process begins to develop from the intermaxillary segment of the maxilla this segment is formed by merging of the medial nasal prominences

Initially

The

primary palate forms the premaxillary part of the maxilla


represents only a small part of the adult hard palate

It

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The

secondary palate is the primordium of the hard and soft palate begins to develop early in the sixth week from two mesenchymal projections that extend from the internal aspects of the maxillary prominences

It

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Initially

the lateral palatine processes or palatal shelves project inferomedially on each side of the developing tongue

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As

the jaws develop, the tongue becomes relatively smaller and moves inferiorly the 7th & 8th weeks, the lateral palatine processes elongate and ascend to a horizontal position superior to the tongue

During

Gradually

these processes approach each other and fuse in the median plane
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EXTRINSIC FORCES
1.Altered position of tongue 2.Shelves pushed up by tongue 3.Mouth opening reflexes

INTRINSIC FORCES
1.Developmnt of intrinsic forces 2.Variation in vascular bed 3.Biosynthetic activity inside the mesenchymal tissue 4.Due to absorption of fluids

Palatine

processes also fuse with the nasal septum and the posterior part of the primary palate

The

nasal septum develops as a downgrowth from internal parts of the merged medial nasal prominences
fusion between the nasal septum and the palatine processes begins anteriorly during the ninth week and is completed posteriorly by the twelfth week
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The

Palatal

shelves move medially and fuse with the nasal septum.


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Bone gradually develops in the primary palate, forming the premaxillary part of the maxilla, which lodges the incisor teeth Concurrently bone extends from the maxillae and palatine bones into the lateral palatine processes to form the hard palate The posterior part of these processes do not ossify.

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They

extend posteriorly beyond the nasal septum and fuse to form the soft palate. Its soft conical projection is called uvula
The

median palatine raphe indicates the line of fusion of the lateral palatine processes
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The

defect is usually classified according to developmental criteria There are two major groups of cleft lip and palate:

Clefts

involving the upper lip and anterior part of the maxilla

Clefts

involving the hard and soft regions of the palate


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In

cleft patients obturators are needed to assist in feeding. Also palatal lift prosthesis are used for improving palatopharyngeal incompetence. Nasoalveolar moulding appliances are given in presurical orthopedics.

The

development of the tongue begins in the 4th week with the differentiation of the two lingual swellings and the tuberculum impar from the mandibular arch. A second median swelling the copula or the hypobranchial eminence develops from the 2nd,3rd and part of the 4th arch. A third median swelling develops from the 4th arch which forms he epiglottis.

ANKYLOGLOSSIA

AGLOSSIA

MICROGLOSSIA

Normally selective degeneration of cells takes place around the frenum which frees it from the tongue from the floor of the mouth. Ankyloglossia prevents the tongue from touching the palate and causes defective production of sibilants and lingual sounds like r. High lingual frenum attachment causes interferences with major connectors in RPDs. Macroglossia decreases denture stability by decreasing the neutral zone.

Viscerocranium The viscerocranium, which consists of the bones of the face, is formed mainly from the first two pharyngeal arches. The firstarch gives rise to a dorsal portion, the maxillary process, which extends forward beneath the region of the eye and gives rise to the maxilla,the zygomatic bone, and part of the temporal bone. The ventral portion,the mandibular process, contains the Meckel cartilage. Mesenchyme around the Meckel cartilage condenses and ossifies by intramembranous ossification to give rise to the mandible. The Meckel cartilage disappears except in the sphenomandibular ligament. The dorsal tip of the mandibular process, along with that of the second pharyngeal arch, later gives rise to the ear ossicles.

AGE CHANGES IN THE VISCEROCRANIUM At first the face is small in comparison to the neurocranium due to the small size of the bones and the virtual absence of the paranasal sinuses. With the appearance of the teeth and development of the paranasal sinuses the face loses the babyish appearance. At birth the transverse and antero-posterior diameters of the bone are each greater than the vertical. The frontal process of the maxilla is well-marked and the body of the bone consists of little more than the alveolar process, the teeth sockets reaching almost to the floor of the orbit. The maxillary sinus presents the appearance of a furrow on the lateral wall of the nose. In the adult the vertical diameter is the greatest, owing to the development of the alveolar process and the increase in size of the sinus. In old age the bone reverts in some measure to the infantile condition; its height is diminished, and after the loss of the teeth the alveolar process is absorbed, and the lower part of the bone contracted and reduced in thickness.

At birth the body of the bone is a mere shell, containing the sockets of the two incisor, the canine, and the two deciduous molar teeth, imperfectly partitioned off from one another. The mandibular canal is of large size, and runs near the lower border of the bone; the mental foramen opens beneath the socket of the first deciduous molar tooth. The angle is obtuse (175), and the condyloid portion is nearly in line with the body. The coronoid process is of comparatively large size, and projects above the level of the condyle.

After birth the two segments of the bone become joined at the symphysis, from below upward, in the first year; but a trace of separation may be visible in the beginning of the second year, near the alveolar margin. The body becomes elongated in its whole length, but more especially behind the mental foramen, to provide space for the three additional teeth developed in this part. The depth of the body increases owing to increased growth of the alveolar part, to afford room for the roots of the teeth, and by thickening of the subdental portion which enables the jaw to withstand the powerful action of the masticatory muscles; but the alveolar portion is the deeper of the two, and, consequently, the chief part of the body lies above the oblique line. The mandibular canal, after the second dentition, is situated just above the level of the mylohyoid line; and the mental foramen occupies the position usual to it in the adult. The angle becomes less obtuse, owing to the separation of the jaws by the teeth; about the fourth year it is 140.

In the adult the alveolar and subdental portions of the body are usually of equal depth. The mental foramen opens midway between the upper and lower borders of the bone, and the mandibular canal runs nearly parallel with the mylohyoid line. The ramus is almost vertical in direction, the angle measuring from 110 to 120, also the adult condyle is higher than the coronoid process and the sigmoid notch becomes deeper.

In old age the bone becomes greatly reduced in volume due to the loss of teeth and consequent resorption of the alveolar processes and interalveolar septa. Consequently, the chief part of the bone is below the oblique line. The mandibular canal, with the mental foramen opening from it, is closer to the alveolar border. The ramus is oblique in direction, the angle measures about 140, and the neck of the condyle is more or less bent backward.

"Mandibular hypoplasia" It is common in infants, but is usually self-corrected during growth, due to the jaws increasing in size. It may be a cause of abnormal tooth alignment and in severe cases can hamper feeding and may also cause sleep apnoea. While not always pathological, it can present as a birth defect in multiple syndromes including: 1. fetal alcohol syndrome, 2. congenital rubella, 3. DiGeorge's Syndrome, 4. Ehlers-Danlos Syndrome, 5. Pierre Robin syndrome, 6. X0 syndrome (Turner syndrome), 7. Treacher collins syndrome

In disease states, maxillary prognathism is associated with Cornelia de Lange Syndrome; however, so-called false maxillary prognathism, or more accurately, retrognathism, where there is a lack of growth of the mandible, is by far a more common condition.

Maxillary hypoplasia is frequently observed in cleft patients. Although maxillary retrusion can be a syndromic outcome, the growth failure is also a consequence of the primary surgery of the palate, alveolar cleft, or lip. It is also seen in crouzon syndrome and fetal alchohol syndrome.

Pathologic

mandibular prognathism is a potentially disfiguring genetic disorder where the lower jaw outgrows the upper, resulting in an extended chin. This condition is known as Habsburg jaw, Habsburg lip or Austrian Lip due to its prevalence in that bloodline. Acromegaly is caused due to a congenital increase in growth hormone levels which causes an abnormal thickening of the mandible, hands, feet and a generalized increase in the connective tissue.

The

neural crest cells are a very susceptible population as they leave the surface ectoderm and are frequently a target for teratogens. Thus developmental head & neck anomalies are common. Craniosynostosis is a condition in which one or more of the fibrous sutures in an infant skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull.

Crouzon syndrome:wide-set, bulging eyes, beaked nose,flat face Apert syndrome: fused fingers or toes ,flat midface Crouzonodermoskeletal syndrome: wide-set, bulging eyes ,beaked nose, flat face, dark, velvety skin folds, spine abnormalities, benign growths in the jaw. Jackson-Weiss syndrome: enlarged bent big toes, flat midface Muenke syndrome: coronal synostosis, skeletal abnormalities of the hands or feet, hearing loss Pfeiffer syndrome: broad, short thumbs or big toes, webbed or fused fingers or toes.

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TMJ development takes place mostly between the 7th and 20th week of intrauterine life and a particularly sensitive period is morphogenesis between the 7th and 11th week. A particular feature of TMJ development compared to other joints in the human body is mutual approximation of the initial condylar and temporal base (blastema). There are three stages in TMJ development: blastemic stage (7th-8th week; development of the condyles, articular fossa, articular disk and capsule), cavitation (9th-11th week; beginning of lower joint space development and condylar chondrogenesis), and maturation stage (after the 12th week)

The

development of the head and neck is chronologically faster than the rest of the body. Also it is one of he most common sites for developmental anomalies(eg. cleft palate, cystic hygroma, branchial cyst) Thus an understanding of the development of the head and neck and the oral cavity broadens ones perspective in day to day practice.

BIBLIOGRAPHY: 1. LANGMANNS HUMAN EMBRYOLOGY 2. GRAYS ANATOMY 3. Palatogenesis and potential mechanisms for clefting J.J. KERRIGAN, J.P. MANSELL, A. SENGUPTA, N. BROWN and J.R. SANDY Division of Child Dental Health, Department of Anatomy, University of Bristol Dental School, Lower Maudlin Street, Bristol U.K.

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