Development of Naso Maxillary Complex / Orthodontic Courses by Indian Dental Academy

INDIAN DENTAL ACADEMY
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Source: JCO on CD-ROM (Copyright 1998 JCO, Inc.), Volume 1983
Oct(669 - 679): JCO/lnterviews: Dr. Donald H. Enlow on Craniofacial
Growth
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
"equilibrium".
Growth and development of
Nasomaxillary complex
Anatomy
Pre natal growth
Post natal growth
Theories
Nasomaxillary remodeling
Clinical implications
Articles
Summary
Area of Nasomaxillary Complex
Anatomy
Skeletal Tissues / Bones
Maxilla
Zygomatic
Palatine
Lacrimal
Vomer
Nasal spine, septum
Ethmoid
Sphenoid
Anatomy
Sinuses

Maxillary
Frontal
Ethmoid
Sphenoid
Nasal cavity

Radiological appearance
Anatomy
External anatomy of the nose
Muscles attachments
Blood supply
Nerve supply
Lymphatic
Histological features
Relation to surrounding structures
Anatomy Of Maxilla
Two maxillae articulate to form
1. Whole upper jaw.
2. Roof of oral cavity.
3. Greater part of buccal roof, floor and lateral
wall of nasal cavity and part of nasal bridge.
4. Greater part of floor of the orbit.
5. Infratemporal and ptergyopalatine fossae
6. Inferior orbital and pterygomaxillary fissures

Anatomy Of Maxilla
Parts of Maxilla
1. Body Large and pyramidal in shape .
2. Four processes
FRONTAL
ZYGOMATIC
ALVEOLAR
PALATINE
MAXILLA HOUSES THE LARGEST SINUS OF THE FACE THE
MAXILLARY SINUS
Palatine process[maxilla]
Maxillary sinus
Frontal process
Maxillary process [palatine]
Alveolar process
Maxilla Medial View
Horizontal plate of palatine
Nasal notch
Zygomatic process
ANS
Alveolar process
Maxilla - Lateral View
Frontal process
Maxilla
Anatomy Of Maxilla
Anatomy Of Maxilla
1. nasal
2. frontal
3. ethmoid
4. sphenoid
5. maxilla
6. horizontal process of palatine
7. superior concha (ethmoid)
8. middle concha (ethmoid)
9. inferior concha
10. sphenopalatine foramen
11. medial pterygoid plate
12. pterygoid hamulus of medial
plate
Anatomy Of Maxilla
At birth
Adult
Palatine bone
Palatine Bone
Horizontal plate
Perpendicular plate
Pyramidal process
Orbital process
Sphenoidal process
Zygomatic Bone
Cheek prominence
Lateral wall of orbit
Infratemporal fossa
3 Foramen
3 Muscles
Frontal process lateral
palpebral, suspensory
ligament.
Temporal process
Zygomatic Bone
Lacrimal Bone
Smallest most fragile
Articulates with
Maxilla
Frontal bone
Ethmoid bone
Nasal concha

Nasal Septum
The nasal septum is made up
of the following:
perpendicular plate of
ethmoid
vomer
maxilla
septal cartilage
Muscles attached to Nasal
bones Procerus and nasalis.

Vomer
Trapezoid
Posterior part of nasal
septum
Ethmoid
Lateral masses with air cells
ossified at birth
Nasal septum part ossifies
during 1styr
Cribriform laminae ossify in
2nd yr
Crista galli between 2nd
&4thyr
These cartilages fuse with the
lateral masses in the 6thyr
Sphenoid
Three parts
Body
Lesser wing
Greater wing with
the pterygoid processes
fuse during the 1st yr
Spheno-occipital
synchondrosis begins after
puberty
External nose
Covered by the integument, and lined by mucous
membrane
The bony frame-work occupies the upper part of the organ;
it consists of the nasal bones, and the frontal processes of
the maxill.
The cartilaginous frame-work (cartilagines nasi) consists of
five large pieces
cartilage of the septum,
two lateral and the two greater alar cartilages, and
several smaller pieces, lesser alar cartilages

The cartilage of the septum (cartilago septi nasi) is
quadrilateral termed the septum mobile nasi.
External nose
External nose
Para nasal Sinuses
Maxillary sinus
Frontal sinus
Ethmoidal sinus
Sphenoidal sinus
Maxillary sinus
Pyramidal shaped
Base - lateral wall of the nasal cavity
Apex - into the zygomatic process
Average - 14.75cc
Floor of sinus is above that of nasal
cavity at birth
Sinus increases 3times ant-post &
5times in height and width
In the inferior end of the uncinate
process, is the ostium maxillare, or
opening from the maxillary sinus
Frontal sinus
The Frontal Sinuses (sinus frontales)
Behind the superciliary arches
Average measurements are as follows:
Height, 3 cm
Breadth, 2.5 cm
Depth from before backward, 2.5 cm
Opens into middle meatus of the nose through the
frontonasal duct
Absent at birth, they are generally fairly well
developed between the seventh and eighth years
Reach their full size after puberty
Ethmoidal sinus
The Ethmoidal Air Cells (cellulae
ethmoidales)
Ethmoidal labyrinth and completed
by the frontal, maxilla, lacrimal,
sphenoidal, and palatine bones
Three groups, anterior, middle, and
posterior
The anterior and middle groups
open into the middle meatus of the
nose
The posterior cells open into the
superior meatus
Develop during fetal life.
Sphenoidal sinus
The Sphenoidal Sinuses (sinus sphenoidales)
Average measurements
Vertical height, 2.2 cm
Transverse breadth, 2 cm
Antero-posterior depth, 2.2 cm
Communicates with the sphenoethmoidal
recess
Minute cavities at birth
Development takes place after puberty
Nasal Cavity
The nasal chambers are situated one on
either side of the median plane
They open in front through the nares, and
communicate behind through the choan
with the nasal part of the pharynx
Nares are somewhat pear-shaped apertures,
each measuring about 2.5 cm - antero-
posteriorly and 1.25 cm - transversely at its
widest part
Choanae are two oval openings each
measuring 2.5 cm. in the vertical, and 1.25
cm. in the transverse direction in a well-
developed adult skull

Radiological appearance
Indices
Cephalic index
Total facial index
Upper facial index
Nasal index
Orbital index
Palatal index
Gnathic index
Para nasal Sinuses
Relations with surrounding tissues
Infratemporal fossa
Ptergyopalatine fossa
Basicranium
Middle ear
Oral cavity
Nasopharynx
Muscle attachments
Blood vessels, Nerves & Lymphatics
External carotid artery
V & VII cranial nerve
Submandibular lymphnodes
Histological Appearance
Olfactory cells, olfactory hairs and glands of Bowman, are
identical in structure with serous glands
The epithelial cells of the nose, fauces and respiratory
passages play an important role in the maintenance of an
equable temperature
Development of Embryo
1
st
week 3
rd
week
Ovum Zygote Blastocyst Gastrula

Neurulation

Development of Embryo
4
th
week
Somites
Neural tube formation
24
th
day 1
st
and 2
nd
arch are distinct
26
th
day 3 pairs of branchial
arches
otic pits appear
4
th
pair of branchial
arches and lens
placodes are visible
C shaped curvature of the
embryo
Branchial Arches
1
st
Arch - Mandibular Arch
2 prominences - mandibular prominence
- maxillary prominence
Bones mandibular,
maxilla,
zygomatic
squamous part of the temporal bone
malleus
incus
Branchial Arches
1
st
Arch - Mandibular Arch
Muscles of mastication
Mylohyoid and anterior belly of digastric
Tensor tympani
Tensor veli palatine
Anterior ligament of malleus
Sphenomandibular ligament
Trigeminal nerve except the opthalmic division
Maxillary artery
Meckels cartilage
Branchial Arches
2
nd
Arch - Hyoid Arch
Bone - hyoid
stapes
styloid process
lesser cornu of hyoid
upper part of body of hyoid

Branchial Arches
2
nd
Arch - Hyoid Arch
Muscles of facial expression
stapedius
stylohyoid
posterior belly of digastric
stylohyoid ligament
Facial nerve
Stapedial artery
Reicherts cartilage
Branchial Arches
Third Arch
Bone greater cornu and the inferior part of the
body of the hyoid bone
Stylopharyngeus
Glossopharyngeal nerve
Common carotid artery
Internal carotid artery
Carotid body
Branchial Arches
Fourth Arch
Thyroid cartilage
corniculate
cunieform cartilage
Muscles cricothyroid, constrictors of pharynx,
palatopharyngeus, uvular muscles of soft palate,
palatoglossus
Superior laryngeal nerve
Left arch of aorta & Right subclavian and
brachiocephalic arteries
Branchial Arches
Sixth arch
Cricoid cartilage
arytenoid cartilage
Recurrent laryngeal nerve
Prenatal embryology
Face - Upper - Frontonasal
- Middle - Maxillary
- Lower - Mandibular
Organizing centers
Prosencephalic - Upper third of face
Rhombencephalic - Middle third of face
1/3
rd
Prominence
th
Shallow depression - Primitive mouth -
Stomodeum

Floor of the stomodeum is formed by the
Buccopharyengeal membrane
Pre-natal growth
At fourth week of of IUL-
1.migration of neural crest cells
2.formation of brachial arches
STOMODEUM
FRONTONASAL
MAXILLARY
MAXILLARY
MANDIBULAR MANDIBULAR
Medial nasal
process
Lateral nasal process
Maxillary process
Mandibular process
Maxillary and Mandibular processes-
first branchial arch
Frontonasal processes- downward
proliferation of mesenchyme of developing
brain
Medial nasal Lateral nasal
Mesenchyme of first arch
maxilla
palatine
mandible
zygomatic
Part of temporal
Nasal process
Median nasal
process
Lateral nasal
process
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
intermaxillary
nasopalatine
At Eighth Week IUL
Two intermaxillary ossification centers generate
the alveolar ridge and primary palate
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
Twelfth Week
Growth of palate

1
st
trimester-narrow
2
nd
trimester-moderate width
3
rd
trimester- wide
Breadth>length
Height changes less dramatic
Growth of palate
Two primordia, primary palate and
secondary palate

Pre-natal Growth and development of palate
Formation of primary and secondary palate

Elevation of palatal shelves

Fusion of palatal shelves
Early palate formation
28
th
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 palate
Primary palate
5
TH
week IUL 12
TH
week IUL
6
9
CRITICAL PERIOD www.indiandentalacademy.com
Primary palate
Frontonasal
process
Medial nasal
Mesenchyme
Wedge shaped mass
between internal
surface of maxillary
prominence
Primary palate
Pre-maxilla
Primary palate
Primary palate
Secondary palate
2 horizontal mesenchymal projections
Maxillary prominence
Lateral palatine process
Fuse-
With each other
Primary palate
Nasal septum
Secondary palate
Secondary palate
Palatal Shelves
At 6 weeks
1. Tongue {undifferentiated tissue}
pushes dorsally
2. palatal shelves become vertical
3. Elevation occurs from vertical to horizontal
position
Elevation of palate
Nasal
septum
Palatal
shelves
Tongue
Histological section

Muscular
movement
Pressure
differences
Biomechanical
transformation
Intrinsic shelf
force
Differential
mitotic growth
Withdrawal of
embryos face
Vascular
changes
Increase in tissue
turger
Elevation of head and lower jaw
Fusion of palatal shelves
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
Ossification of the palate
Premaxillary centres
Primary ossification centres of each palatine
bone
Y shaped midpalatal suture
T shaped midpalatal suture
No ossification at the soft palate region
8
th
wk

10
th
wk

Childhood
Musculature of palate
Tensor veli palatini 40 days 1
st
arch
Palatopharangeous 45 days
Levator veli palatini 8
th
week 2
nd
arch
Palatoglossus 9
th
week
Uvular muscle 11
th
week 2
nd
arch
Growth in dimensions

Length - 7-8 weeks IUL
Width - 4
th
month onwards
height
width
length
Arched palate
Growth in dimensions
Pre natal life (appositional growth in the alveolar margin)
length > width

At birth (appositional growth in the maxillary tuberosity)
length = width

Post natal life
width > length
Elevation of head and lower jaw
Oxygen and nutritional deficiency
Excess endocrine substances
Drugs
Irradiation
Vascularity

teratogen
s
Maxillary sinus
PRE NATAL
lateral evagination of mucous membrane in
middle meatus 3
rd
month IUL
AT BIRTH
2mm -long, 1mm in width + height
PNEUMATISATION
PRIMARY
SECONDARY
Neonatal Skull
Genesis of cleft lip and palate
Associated with more than 150 syndromes
Aetiology
Mutant gene or chromosomal aberrations

- Monogenic
- Polygenic
Etiology of cleft lip / palate
Infectious
agents
Irradiation
Drugs
Nutritional
deficiency
Excess
hormones
Smoking
and
alcohol
Separation due to wide growing brain and
cranial floor
Separation due to tongue
Biochemical or tissue barrier intercedes
between the fusing parts
Primary failure in the fusion
Genesis of cleft
Cleft lip usually seen at the
philtrum and the lateral part of
the upper lip

Harelip

Bifid nose
Prenatal anomalies
Formation of
germ layers
Day 17
Fetal alcohol
syndrome
[mid face
deficiency]
Migration and
proliferation
of cell
population
Day 19-28
Treacher Collin
syndrome
Prenatal anomalies
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 palate
Other syndromes
Downs syndrome
Hurlers syndrome
Cebocephaly
Scaphocephaly
Apert syndrome
Cyclops
Van der Woude syndrome
Craniostenosis
ANOMALIES OF PALATE
Epithelial pearls

ANOMALIES OF PALATE
Torus palatinus
ANOMALIES OF THE PALATE
High arched palate
MARFANS
SYNDROME
CROUZON
SYNDROME
CLEIDOCRANIAL
DYSOSTOSIS
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]
ANOMALIES OF PALATE
Cleft palate
Failure of fusion of the lateral palatine
process with each other or with the
median palatine process
Failure to fuse after
contact as epithelium
does not break down

Rupture after fusion

Defective merging
Bifid uvula
Unilateral
cleft palate
Bilateral
cleft palate
Bilateral cleft
palate
Bifid uvula
Unilateral cleft palate
Classifications
Davis and Ritchies : (1922)

Group I prealveolar clefts

Group II postalveolar clefts
: cleft involving hard and soft palate

Group III Cleft of both primary and
secondary palate
Veaus classification : (1931)
A. Cleft lip

class I : U/L notching of vermillion border, not
extending into the lip.

class II : cleft extending into the lip, but not
including the floor of the nose.

class III: extending into the floor of the nose.

class IV: any b/l cleft of the lip, whether
incomplete or complete.
B. Cleft palate

class I : soft palate

class II : soft/hard palate extending no
further than incisive foramen

class III: complete u/l cleft, extending from
uvula to incisive foramen, then
deviating to one side

class IV: two clefts extending forward from
the incisive foramen into the
alveolus
Fogh Andersons Classification (1946)
1. Hare lip cleft

2. Hare lip cleft associated with cleft palate

3. Isolated cleft palate

Kernahan / Starks (1958)
1. Cleft of primary palate

2. Cleft of secondary palate

3. Cleft involving both primary and secondary
palate.
Interdisciplinary approach
Genecist
Orthodontist
Oral Maxillofacial Surgeon
Prosthodontist
Plastic Surgeon
Paediatrician
Social workers
Psychiatrist / Psychologist
Speech Pathologist / Therapist
Audiologist
Nursing services
Stage I
Maxillary Orthopedic stage Birth to 18 months
Mc Neil 1950 prosthetic devices
Obturator
False plate
Maxillary cross arch stability
Maxillary orthopedic molding
Premaxillary orthopaedics birth to 5
months
1686 Hofman
Use of headcap and premaxillary strap to
reposition the premaxilla
Cheiloplasty
Rule of Tens
10 weeks of age
10 pounds of body weight
10 grams of hemoglobin
Maxillary orthopaedics 3 to 9 months

Obturator to provide cross arch stability
Stage II - Primary dentition - 18 months to 5 yrs

Stage III - Late primary or mixed dentition 6 to
11 yrs

Stage IV Permanent dentition 12 to 18yrs
Grafting procedures
Palatoplasty - 1 to 2 yrs
Primary bone grafting < 2 yrs
Early secondary bone grafting 2 to 4 yrs
Secondary bone grafting 6 to 15 yrs
Late secondary bone grafting Adult

Graft from RIB - 2cms is harvested
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
Dental deformities
Natal or neonatal teeth
Congenitally missing teeth
Supernumerary teeth
Ectopic eruptions
Altered tooth morphology
Deficient alveolar bone support
Rotations, deviations in axial root inclinations
Posterior cross bite
Mobile and protuberant premaxilla
Convex profile

General features
Three dimensional growth of maxilla
Height (Vertical)
Width (Transverse)
Length (Ant-Post)
Theories of growth
Sutural
Cartilaginous
Functional matrix theory

Key factors in Nasomaxillary remodelling
Displacement
Primary displacement

Secondary
displacement
Reversal 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
Surface remodeling

Displacement

CRANIAL BASE MAXILLA
apposition resorption
MOSS
Transformation
Translation
SUTURES
Mechanism of growth
Sutural
Nasal septum
Surface apposition and resorption on
periosteal and endosteal surfaces
Alveolar process
Spheno occipital synchondrosis

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

Endochondral bone growth seen at the
ethmoid bone and nasal septum

Surface apposition
Spheno occipital synchondroses
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 synostosis
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 the tuberosity
allows for arch expansion by moving the teeth
posteriorly into the area of bone deposition

Extensive scope for growth modification before
adolscent 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 surgery
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
Effects of Dentition and Occlusion
Bimolar width in the 1
st
molar region correlates
- Vertical growth of maxilla
- Growth in the midpalatal suture
- growth in height
Effects of Dentition and Occlusion
Maxilla drifts 5mm forward in molar region
(by adolscence)
- 2.5mm in incisor region
Shortening of the arch perimeter associated with
eruption of 2
nd
molar
Initiation of eruption of 3
rd
molar occurs after the
greatest shortening of length in the maxillary dental arch
Shortening of anterior segment mesial drift of teeth
crowding of ant segment convergence and narrowing of
the bone base

Growth in height vertical

Growth in width transverse

Growth in length A - P
Vertical growth
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
Deposition on the oral
side

Resorption on the
nasal side
ENLOW AND BANG V PRINCIPLE
V principle of Bang and Enlow
Entire v shaped
structure moves in a
direction towards
the wide end of the
v
Remodeling of palate
H EIGHT
APPOSITION IN THE
ALVEOLAR PROCESS
ERUPTION OF TEETH
Sagittal view Coronal view
HEIGHT - V PRINCIPLE

Primary displacement
HEIGHT
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
WIDTH
This growth mimics the general growth
curve

Mutual transverse rotation of the two
maxillae results in more separation of the
halves in the posterior than the anterior
segment
LENGTH
Begins rapidly in the 2
nd
year of life
Maxillary
tuberosity
Palato
maxillary
suture
primary secondary
displacement
LENGTH
Resorption in the anterior region of the
maxilla
Maxilla rotates in relation to the anterior
cranial base
Bjork and Skieller implant studies have
shown that anterior surface is stable
sagittally
Timing
Alveolar process eruption of teeth
Overall height along with
- Vertical growth of mandible
- General body growth curve
Compensatory mechanism
Narrow palate alveolar process compensates for
width and height
Deep bite Occ plane parallel to mandibular plane
Long anterior surface Steep occlusal plane
Adaptive nature Class I molar relation though
skeletally retrognathic
Orthodontic correction totally dependent on the
adaptive capacity of alveolar process remodelling
Theories of growth

SUTURAL THEORY

CARTILAGENOUS THEORY

FUNCTIONAL MATRIX HYPOTHESIS
Sutural Theory
Sutures have innate growth
potential
Push bones apart
Oblique in nature
Sliding effect
Resultant thrust in the
anterior and inferior
direction
Weinman & Sicher
Sutural Theory
Shortcomings
- Bone tissue in not capable of growth in a field
that requires level of compression needed to
produce a pushing type of displacement
- Suture is essentially a tension adapted tissue
- Sutures do not have inbuilt growth potential
Cartilagenous theory
Nasal septum innate growth potential

Thurst effect septomaxillary ligament growth in
fields of compression

More of forward and downward force than vertical

Bone enlarges at the sutures in response to the tension
created by displacement
Surgical removal of Nasal septum
Scott
Removal of nasal septum mid face deficiency
Cartilagenous theory
Shortcomings
Nasal septum functions to support the roof of the nasal
chamber
Doesnt displace the palate by itself
Reasons
Source of maxillary displacement is multifactorial
Exptl studies merely show that groeth process functions
in its absence rather than in its presence

Functional matrix hypothesis

Basal body Infraorbital nerve

Orbital unit Eyeball

Nasal unit Septal cartilage

Alveolar unit Teeth
Moss
SKELETAL UNITS
FUNCTIONAL MATRIX
Functional matrix hypothesis
Height
Enlarging
orofacial
capsule
Remodelling
changes in the orbit
Soft 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.
The Nasomaxillary Complex Remodeling
The Lacrimal Suture
The Maxillary tuberosity
Key ridge
Vertical drift of teeth
Nasal airway
Palatal remodelling
Downward maxillary displacement
Maxillary sutures
The Cheekbone and Zygomatic Arch
The paranasal sinuses
Orbital Growth
Lacrimal bone
Bounded by sutural connective tissue
Undergoes remodelling rotation medial superior part
remains with the nasal bridge, - inferior part moves
outwardly with the ethmoidal sinuses
Provides slippage of multiple bones along sutural
interfaces perilacrimal sutural system
Maxilla slides downwards along its orbital contacts
Developmental gridlock would develop without this
system
Maxillary tuberosity
Established by the posterior boundary of
anterior cranial fossa
Helps in posterior and horizontal
lengthening of arch
Anterior displacement= posterior lengthening
lateral widening
downward deposition
Contributes to
maxillary sinus enlargement
Key ridge
Vertical crest below the
malar protuberence
muzzle
Reversal occurs at the
key ridge
Posterior - apposition
Anterior - resorption
Vertical drift of teeth
Vertical drift significant intrinsic growth factor
provides intramembranous bone remodelling
Moves the tooth in its socket usually called
extrusion
mesial drift well known process Vertical drift
not a part of everyday vocubulary

Nasal airway
Lining surface of bony
wall and floor
Resorptive
(except olfactory fossae)
Downward relocation of
palate
Lateral and anterior
expansion
Downward cortical remodelling of entire anterior
cranial floor & lateral and inferior depositions on
ethmoidal conchae
Nasal airway
Ethmoidal conchae
- lateral + inferior
deposition
- medial + superior
resorption

Inter nasal septum
- lengthens vertically at
sutural junctions
Palatal remodelling
V principle
Bone deposition on the inside of the arch
Growth along the mid palatal suture
Grows inferiorly exchange of old palate for
new hard and soft tissues occurs
Primary displacement of the ethmomaxillary
complex inferiorly

New bone is added at all sutures and these sutures
accompany displacement produced by the soft
tissues
The balance of > or < growth in posterior and anterior
maxilla is due to clockwise/counterclockwise rotatory
displacement caused by downward and forward growth
of the middle cranial fossa

Nasomaxillary complex undergoes compensatory
remodelling rotation to sustain its position relative to
the vertical reference line and to the neutral orbital axis
Maxillary sutures
Sutures slide or slippage of bones along the interface

Remodelling and relinkage of the collagenous fiber
connections within the sutural connective tissue causes
the displacement process

Cheek and zygomatic bone
Posterior side of malar protuberence within the temporal
fossa is depository
Cheek bone relocates posteriorly as it enlarges
Posterior relocation slows after dental arch length is
achieved during childhood
Zygomatic arch moves laterally by resorption on the
medial side
Zygoma and cheekbone complex are displaced
anteriorly and inferiorly in the same directions as the
maxilla
Zygomatic region
Posterior relocation
anterior posterior
Increase in height
frontozygomatic
Inferior
border
Lateral growth
displacement
Zygomaticotemporal [anterior]
Frontozygomatic [inferior]
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 continuous
downward growth
close proximity to buccal
maxillary teeth
Orbital growth
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
A Text Book of Oral Pathology
SHAFER, HINE, LEVY
JCO/lnterviews: Dr. Donald H. Enlow on
Craniofacial Growth Volume 1983 Oct
(669 - 679)
References
Moyers 3
rd
edition
Dentistry for child and adolescent -
MAC DONALD
Clinical pedodontics - FINN
Color atlas of Embryology-
MOORE,PERSUAD
Hand Book of Facial Growth-ENLOW
Grays Anatomy 38
th
Edition
Previous Seminars By - Dr.Chatura
Hegde, Dr Ravi Tej, Dr.Harshavardhan
Kidiyoor and Dr Jaya Kothari.

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

Thank you

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