Orthodontics-Lecture 2 october-2013

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CranioFacial growth

Today we are going to talk about craniofacial growth and you need to understand how growth takes place in the craniofacial region, upper jaw, lower jaw and perioral areas. What does growth mean? Growth is an increase in the size and number. However there is a difference between growth and development Development means an increase in the specialization of function. There are two terms which are really important and you should be able to distinguish between them which are, -Growth site: it's the location at which growth occurs, in this site the growth occurs as a response to stimulus; stimulation from other source will stimulate growth. For example the cranial vault has sutures at which growth occurs we call the sutures "Growth sites". The cranial vault growth takes place as a result from a stimulus which is the brain, when the brain starts to increase in size it stimulates the cranial vault to accommodate the brain. So the cranial sutures are growth sites. - Growth center doesn't need stimulation; it grows by itself and it is genetically controlled Innate growth potential.

Growth center can act as a growth site. But the growth site cannot act as a growth center. * All centers of growth are sites of growth but not all sites of growth are centers of growth.

**What does initiate growth? It's initiated by growth hormones which are released from pituitary gland. **What does control the extent and timing of growth? Genetic control for growth center, by homeobox genes provides the blue print for growth and development. Environmental control for growth site, by 1-physical stress in emotionally deprived child inhibits growth hormone release 2- nutritional status 3-functional matrix theory, it states that growth will take place as a result of functional demands. For example the Africans have big noses and wide nostrils because of the weather there and they have problem in breathing so they inhale and exhale excessively, so the functional demand is high accordingly they have big noses.

*Concepts of Growth: 1. Pattern: it means growth with time tends to go down.

2. Variability: it means that it differs from one to one for

example you may see 12 year old male and he looks 17 year old, he looks mature whereas you may see 12 year old male and he looks 9 year old.

3. Timing: it's also variable from one to one, but there is a time where the peak of growth will take place this is called "Growth spurt"

Concepts of Growth

Growth pattern: cephalo-caudal pattern

Proportionality growth in certain areas is more than others and with time it may be reversed. The proportion of one part relative to the other part, for example the growth of the mandible relative to the growth of maxilla; at the beginning the maxilla grows more than the mandible but with time the mandible will grow more than the maxilla.

*Aspects of growth pattern:

Growth pattern with time will go down and we call it " cephalocaudal gradient of growth"; cephalo means the head & caudal means tail. In early stages the growth will be mainly in the cephalo region. With time it moves toward the caudal. Increased growth towards the foot end after birth.

Effect in the craniofacial region *At first the Cranium will grow faster than maxilla and the maxilla faster than the mandible *With time after birth the mandible will go faster than the maxilla

> Thats why most of young children will have class II because the maxilla goes faster than the mandible, so the mandible will catch with the maxilla.

Pattern of growth is not only in the direction of growth it is also related to the tissues. Different tissue systems also grow in different rates for example muscular, skeletal, genital, neural and lymphoid will grow in different rates; muscular and skeletal elements grow faster than brain and nervous system.

This figure represents the different rates of growth of different tissues, the lymphoid tissues grow faster until person is around 12 years old then it will decline that's why tonsillectomy and adenoids most of the time are made for children because they will be in a big size in children. Neural tissues> will grow until it will be stable that's why anything dies in neural system will never come back to normal. General "skeletal and muscular"> it will grow with time until around 18 year old Genital > slow growth until person reaches puberty then it grows quickly until certain limit.
Concepts of Growth:

Variability
Growth is variable from one to one due:

1- Variability in genetic input 2- Variability of environmental factors (where person lives, stress, emotions) 3- Variability in functional demands 4- Variability in functional response

Concepts of Growth:

Timing of growth

> It's variable from one to one, and it is variable from male to female; females usually grow quicker than males. Females reach growth spurts before males usually 2 years before males > Growth spurts are evident in adolescence > Growth spurts occur at different times in different individuals. > Timing variability can be reduced by using developmental age (how does person look) rather than chronologic age (number of years) as an expression of an individual's growth status. For example, sometimes person may look 17 years old although he is chronologically 12 years old and sometimes other chronologically growth person may look younger. *Developmental age also called physiologic age.

Growth in different directions In the craniofacial region we said that we look at the patient in 3 dimensions, anterior-posterior, vertical, transverse. Also timing of growth is variable in dimensions. Growth in width stops first while the growth in vertical dimension ends last.

It is important to us because if I want to do maxillary expansion (increase the width) I have to know when does the width stop. So the sooner you start the better you get. Whereas the height it may last to the early adulthood periods Growth of width is first completed then growth in length and finally growth in height.

Growth in width is usually completed before the adolescent growth spurt. Growth in length and height of both jaws continues through the period of puberty.

-How growth of tissues occurs? Hyperplasia increase in number of cells (increase in cell
division)

Hypertrophy increase in the size of the cells.

The other component is the extracellular fluid; if it increases it will increase the size of the whole tissue.

Types of Growth: 1- Interstitial growth means growth from inside within

the whole tissue and it occurs in all soft tissues and non mineralized cartilage like vascular system, muscular system and neural system mainly by:

-hyperplasia Hypertrophy Secretion of extra-cellular materials

2- Surface apposition means growth on the surface

adding layer by layer and it occurs in bone. Formation of new cells occurs at the periosteum and secretion of extracellular material which mineralize later to form a new layer of bone.

*Bone can be delivered either by: -intra membranous ossification - Endochondral ossification

*Three mechanisms are responsible for the growth of the bone: 1- Conversion of cartilage into bone this is called endochondral ossification

2- Surface deposition or (sutural growth) from periosteum a new layer of Osteoblasts and will be ossified later on to bone and this takes place by intra-membranous ossification

3- Subperiosteal remodeling, (subperiosteal means beneath the Periosteum in the inner surface)

*Endochondral Bone Formation:

It means cartilage at the beginning which will ossify later to form bone; the original mesenchymal tissue becomes cartilage then cartilage cells hypertrophy, the matrix become calcified then the cells degenerate and the osteogenic cells invade the cartilage and replace it.

*Intra-membranous Bone Formation:

The undifferentiated mesenchymal cells of the membranous connective tissue change to Osteoblasts and osteoid matrix. The matrix or inter-cellular substance becomes calcified and bone results.

No cell division occurs inside the bone (no interstitial growth) and the growth occurs in surface and is called appositional growth.

Deposition is the laying down of new bone cells in layers and it's done by Osteoblasts and in order to maintain the shape of the bone resorption must happen and it's done by Osteoclasts. Apply this on the cranial vault, the brain will stimulate the cranial vault to grow larger by surface deposition from outside, but in the other hand resorption must occur from inside so that the brain can find space to grow.

*Cartilage growth undergoes interstitial growth from inside and appositional growth at surface.

Done by :sawsan Jewiad

Second part of the 2nd lecture ,, Now lets start with the development of calvarium which contains: 1-cranial vault 2cranial base

Cranial vault : flat bones separated by

sutures. Composed of frontal , parietal , temporal and occipital bones. These bones develop from the membranous covering of the brain .

-At birth : bones are separated by connective tissue called fontanelles - growth at sutures closes fontanelles around one year after birth but bones remain separated by thin periosteal-lined sutures for years . -osteogenesis spreads from ossifications centers which start at the 8th week intra-uterine , also ossification influenced by underlying neural epithelium .

Growth and remodeling of cranial vault :

-growth at sutures and deposition of bone in the inner and outer surfaces . -enlargement results from displacement by expansible growth of brain accompanied by osteogenesis at sutural margins ; when there is a growth at the sutures area, they start to go away from each other and move up so the cranial vault can go up and grow . -brain growth play a role in patterning the shape of the skull and in directing its growth because the brain give stimulation to the growth sites. -resorptive, remodling and deposition flattens bones as head enlarges , deposition from outside and resorption from inside. -cranial vault achieves > 90% of adult size by age 5 . -So ,, Cranial vault undergoes intramembranous ossification and surface apposition, and at sutures there will be sutural expansion stimulated by brain

growth . resorption occurs at the inner surface and deposition occurs at the outer surface.

Craniosynostosis: is a condition in which one or more of the

fibrous sutures in an infant skull prematurely fuses by turning into bone (ossification).

Cranial base : defined in terms of midsagittal structures

(anterioposteriorly) as extending from basion to nasion including basi-occiput , body of sphenoid , frontal bone , cribriform plate of ethmoid . it can be divided into anterior (nasion-sella) , posterior (sella basion) and middle departments .

- the cranial base is performed in cartilage (the remnant of the primary cartilaginous skeleton) , so the cranial base was cartilage then it was replaced into bone by endochondral ossification . - as we said , the cranial base is divided into three parts ; anterior , posterior and between them there will be a cartilage (its look like a suture , but it isnt a suture) we call it synchondroses ; it is a growth centers means that they grow by themselves (with or without stimulus) .

- ossification centers appear from 3 months foetal life to 1 year, as ossification proceeds , band of cartilage called synchondrosis remain between the centers of ossification . -during the 1st 5 years , growth occurs mainly at the spheno-occipital and spheno-ethmoidal synchondrosis . -growth at fronto-ethmoidal sutures is restricted . cribiform plate attains mature length at 2-3 years . - spheno-ethmoidal synchondrosis closes at 6-7 years . -spheno-occipital synchondrosis closes at 13-16 in males & 11-14 in females. - 50% of cranial base post-natal growth is completed by the age of 3 years .

- synchondrosis are the growth centers of cranial base , also their growth results in anterio-posterior increase of the cranial base length because the bone will go away from each other . - growth is by endochondral replacement at the synchondrosis since it is a cartilage ; The sutures of the cranial base are called synchondrosis as they are of endochondral origin. The direction of growth in these sutures is forwards and upwards carrying the anterior cranial base and the upper face upwards and forwards.

clinical relevance :
* Since the naso-maxillary complex is attached to the anterior cranial base and the mandible attached indirectly to the posterior cranial base , alterations in the angulations between the two parts will affect the maxilla-mandibular relations so we have class I , II , III

development of maxilla :
- starts towards the end of 7th week intra-uterine by the appearance of two centers of ossification within the ectomesenchyme of each maxillary process . there are 2 centers : 1)posterior centers give rise to maxillary proper. 2)anterior centers give rise to pre-maxilla . -these ossification centers appear later than those of mandible . -the main growth center of ossification appears above that part of dental lamina which will form the primary canine tooth germ . it is close to the point at which the infra-orbital nerve gives off the anterior superior dental branch. Ossification then proceeds in several directions : 1- vertically towards the cartilaginous nasal capsule as frontal process .

2- medially into the horizontal palatal folds as palatal process . 3- laterally as zygomatic process .

Palatine bone and pre-maxilla :

-palatine bone arise from a single center of intra-membranous ossification during the 7-8th week lateral to cartilaginous nasal capsule . -pre-maxilla :controversy as to whether this bone exists

Postnatal growth of maxilla :

-entirely by intra-membranous ossification . maxilla articulate via suture with : nasal , lacrimal , frontal , ethmoid , zygomatic , vomer (in the nose) palatine bone and premaxilla . there will be stimulation to the growth of the maxilla by intramambranous.

-postnatal growth occurs by sutural deposition and surface remodeling and growth is in a downward and forward direction , this result in new bone deposition on the superior and posterior sutural attachments . ** in order to move maxilla forward there should be bone deposition posteriorly .

-Enlow differentiated between growth and displacement which is a consequence of growth , the predominant direction of growth is posteriorly with displacement occurring in the anterior opposite direction . - the anterior-posterior dimension of growing maxilla increase to accommodate molar teeth.

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growth of maxilla in :
Width : sutural deposition (mid palatal suture)

2AP (anterio-posterior) : sutural and surface remodeling . deposition of bone at posterior surface of maxillary tuberosity accompanied by resorption

at the anterior surface of maxillary complex . to maintain the shape of maxilla there will be bone resorption anteriorly and deposition posteriorly 3height : - eruption of teeth results in growth of alveolar bone . - palate : resorption at nasal side and deposition at mouth roof (drifting) .

* Bone deposition occurs at : tuberosity region , roof of the mouth , median wall of maxillary sinus, palatal side of dental arch and alveolar processes as teeth erupt.

* Resorption occurs at : -anterior surface of the maxilla except the anterior nasal spine , nasal side of the roof of the mouth , all walls of maxillary sinus except the inner part of the medial wall , nasal side of the medial wall of maxillary sinus .

Mandible development :

-Development of mandible begins as a condensation of mesenchymal cells just lateral to meckels cartilage and proceeds as intra-membranous bone formation . -the primary centers of ossification lies at the bifurcation of the mandibular nerve into its mental and incisive branches . -meckels cartilage disintegrates and largely disappears as the bony mandible develops , although mandible develops in a close proximity to meckels cartilage , it is classified as membranous bone.

 -fate of meckels cartilage : disappears except 1 or 2 remnant seen in the region of symphysis and persists until birth. The fibrous perichondrium forms spheniomandibular ligament (attach to lingual) and anterior ligament of the malleus(which is in the middle ear) and the dorsal end of the perichondrium forms the malleus and the lncus .

Secondary growth cartilages called secondary because they are not remnant of primary cartilaginous skeleton like : -condylar cartilage : :develops as an independent secondary cartilage 10-14 weeks IU>> early in fetal life it fuses with the developing mandibular ramus and contributes to postnatal mandibular growth. - symphseal cartilage : unites the 2 halves at the symphsis and disappears at the 1st year after birth . - coronoid cartilage : a strip along the anterior border of the coronoid process , disappears before birth .

postnatal growth of the mandible ;

-Both endochondral and intra-membranous growth ; *endochodral growth occurs at the condylar cartilage *intra-membranous growth occurs at the rest of the mandible .

**There will bone deposition posterior surface of the ramus and resorption in the anterior surface of the ramus in order to move the mandible downward and forward.

**so the growth of the condyle occurs upward and backward to move the mandible downward and backward.

-Bone deposition occurs at : outer surface of the mandible , posterior surface of the ramus and chin . -Bone resorption occurs at : inner surface of the mandible ,anterior surface of the ramus and above the chin ( thats why this area is concave) .

Done by : Rasha Al-Shboul