Growth usually refers to an increase in size.

Todd 1931.
????????????

Growth may be defined as the normal change in

the amount of living substance . moyers 1988.

biologic process by which the living matter gets

larger.
 Development is a progress towards maturity
Todd- 1931.

Development is increase in complexity. Profitt

1986.

Development refers to all naturally occurring

progressive, unidirectional, sequential changes
in the life of an individual from its existence as
a single cell to its elaboration as a
multifunctional unit terminating in death
Moyers.
Differentiation: means change in quality

Translocation: means change in position

Development =
Growth + Differentiation + Translocation
 Growth Development
Its defined as increase in size Its defined as progression
toward maturity

Quantitative changes Qualitative changes (Growth +

Differentiation + Translocation )

Anatomic phenomenon Physiologic & behavioral

phenomenon
 Growth site Growth center
Is any location where growth takes place is any location where genetically controlled growth
takes place

Is a region of periosteal or sutural bone Are places of ossification with tissue separating force
formation and remodeling resorption adaptive to
environment

Sites of growth when transplanted to another area Centers of growth when transplanted to another area
doesnt continue to grow continue to grow

Marked response to external influences Less response to external influences. More response to
functional needs

They dont cause growth of the whole bone Cause growth of the major part of the bone
instead they are simply places where exaggerated
growth take place

All growth sites are not growth centers All growth centers are growth sites
Theories of growth are not based on growth site Various theories of growth are based on the place where
growth center is expressed

Growth sites dont control the overall growth of Growth center controls the overall growth of the bone
the bone
There are 6 types of bone found within the human
body.

Long. Femur and Tibia

There are 6 types of bone found within the human
body.

short. Carpals
There are 6 types of bone found within the human
body.
flat. Skull, Pelvis and Ribs
There are 6 types of bone found within the human
body.
pneumatic. Maxilla and frontal bones
There are 6 types of bone found within the human
body.
irregular. Vertebrae and Mandible
There are 6 types of bone found within the human
body.
Sesamoid Irregular bones,
imbedded in a tendon.
 Vital staining:
After injection of dye to animals,
it remains in bones and marks the location at
which active growth occurs, so it will be possible
to study site of growth, direction of growth,
duration of growth.
 Radio-isotopes:
When elements are injected into
tissue, get incorporated in bone and act as vivo
marker.
 Implants:
It can be used in human.
Inert metal pins or titanium inserted into bones
including face and jaw

These serve as radiographic reference point for

the serial radiographic analysis.
 Natural marker :
bone has certain
histological feature such as:
trabeculae, nutrients canal..

By means of serial radiographs

theyre used as reference to study
bone deposition, remodeling and
resorption.
 Craniometry:
Measurements of skull
 Radiographic technique:
Cephalometric and hand &wrist x-ray
 Bone formation takes place by two basic
methods:

1- Endochondral bone formation

2- Intramembranous bone formation

 Endochondral bone formation
It involves production of bone in areas where
there is high level of compression.

Thus, its seen in the cranial base & movable

joints.
 The original mesenchymal tissue first become cartilage

Cartilage cell hypertrophy & their matrix begins to get

calcified

During this time, blood vessels penetrate the cartilage

mass from the perichondrium.
These blood vessels carry undifferentiated mesenchymal
cells which differentiate into osteoblasts.

Cartilage cells degenerate and the osteogenic tissue

invades the dying and disintegrated cartilage and replace
it, thus the endochondral bone doesnt form directly from
cartilage but osteoblasts invade the cartilage and replace
it
1. Cartilage growth takes place
by interstitial growth and
apposition whereas in bone
interstitial growth is not
possible
2. Cartilage, unlike bone, is
pressure adapted tissue and
can grow in heavy pressure
area e.g. cranial base
3. Linear growth takes place
allowing lengthening of bone
whereas in bone , growth is
unidirectional.
4- Cartilage provides three basic
growth functions
Flexibility: support for
appropriate structure e.g. nose

Pressure tolerance : in specific

sites where compression occurs
e.g. articular surface in long
bone
Growth site in conjunction with
enlarging bone
e.g. synchondrosis of cranial
base and condylar cartilage
 Intramembranous bone
formation
Intramembranous ossification is the predominant
mode of growth in the skull.

It occurs on periosteum, endosteum, sutures and

periodontal ligament.

It occurs in area of tension

 The undifferentiated mesenchymal cells of the membranous
connective tissue changes into osteoblast and elaborate osteoid
matrix.

Osteoblast produce bone matrix and surrounded collagen fiber and

become osteocyte.

As the result process bone trabeculae will develop

Trabeculae will join together to produce spongy cell

Cells in the spongy cell will specialize to produce red bone marrow
Cells surrounding the developing bone will produce periosteum

The matrix become calcified, and bone result.

 Deposition and resorption
Remodeling
Growth sites
Growth centers
Growth movement
drift
displacement
Deposition and resorption
Bone change in shape and size
by 2 mechanisms:
deposition and resorption.

Deposition occurs in the surface

facing the direction of growth.

Resorption occurs in surface

facing away from growth.

A combination of bone deposition and resorption

results in growth movement towards the depositing
surface called cortical drift.
Remodeling
Its the differential growth activity involving
simultaneous deposition and resorption in the
inner and outer surface of bone.
This results in changes in size and shape of given
bone, it also produces regional adjustments that
adapt to the developing function of bone.

E.g: growth at the condylar cartilage elongates the

mandible, causing anterior displacement, while its
shape is maintained by remodeling, including
posterior drift of the ramus.
Remodeling
 Growth sites
Growth fields having special
role in the growth of the
particular bone(grows fast)
are called growth sites.
e.g. mandibular condyle,
maxillary tuberosity,
synchondrosis of the
basicranium, sutures and the
alveolar bone.
 Growth centers
Special areas which are
believed to control the
overall growth of the bone
e.g. mandibular condyle.

But according to recent

studies these centers do not
control the whole growth
process.
 Growth Movement
Cortical drift:
Combination of deposition and resorption results
in growth toward the deposited surface.
Drift is produce by deposition of new bone on one
side of the cortical plate while resorption occurs in
the opposite side.
Drift occurs in the direction of bone deposition
If implant placed on surface of deposited side of
cortical plate, it becomes gradually embedded in
cortex as new bone continues to be formed.
Displacement
Movement of whole bone as one unite.
There are 2 types.
1. primary displacement.

2. Secondary displacement.
 primary displacement:
Bone gets displaced as result of its
own growth.
As a result of bone remodeling and
changes in its shape and size, the
bone itself will change its position in
space.
The growth of the maxilla at the
tuberosity region in posterior
direction results in pushing the
maxilla against the cranial base
which results in displacement of
maxilla in forward and downward
direction
Secondary displacement:
displacement of bone as
result of growth and
enlargement of adjacent
bone.
e.g., growth of the cranial
base causes the forward
and downward
displacement of the
maxilla
The major theories explaining growth are
1. Genetic Theory
2. Sutural Theory
3. Cartilageneous Theory
4. Functional matrix Theory
5. Van Limborghs Theory
Genetic theory:

Genetics determine the overall

growth control

This theory is more of an

assumption and its not
proved
Sutural dominance theory
(Sichers hypothesis)
stated that cranio facial growth occurs at sutures.
Sutural growth is the proliferation of the
connective tissue between the two bones.
Points against sutural theory:

Growth takes place even in absence of sutures

Transplantation of zygomatico-maxillary
suture in guinea pigs did not grow.
CONCLUSION:
Sutures are growth sites not centers.
Cartilageneous Theory
(Scotts hypothesis)
Intrinsic growth-controlling factors are in
cartilage & periosteum.
Sutures are secondary & dependent on
extrasutural influences.
Cartilaginous part of skull must be recognized as
primary centers of growth, with nasal septum
being a major contributor in maxillary growth.
Cartilageneous Theory
(Scotts hypothesis)
Scotts hypothesis was based on the principle
that cartilage is a pressure adapted tissue, so
growth of the cartilage in the nasal septum
provides force that displaces maxilla downward
and forward (nasal septal theory)
In mandible, condylar cartilage is considered to
be the growth center present bilaterally with the
U-shaped mandible in between
Functional matrix Theory
Given by MELVIN MOSS IN 1969.

The origin, growth and maintenance of all skeletal

tissues and organs are always secondary,
compensatory and obligatory response to all
changes that occur in specifically related non-
skeletal tissues, organs or functional spaces
Functional matrix Theory
MOSS said that head and neck region consist of
number of functions
Digestion
Respiration
Speech
Olfaction
Balance
Vision
Functional matrix Theory
Each of these function is completely carried out by
FUNCTIONAL CRANIAL COMPONENT
The functional cranial component is divided into

1. functional matrix:
soft tissue muscle, gland, nerve,
vessels, fat and teeth
2. skeletal unit:
bone, cartilage
All non skeletal functional units adjacent to skeletal
unit bringing transformation of the related skeletal
units
Van Limborghs Theory:
He combines all the existing theories
He supports the functional matrix theory with
some aspects of Sutural theory, and doesn't
rule out the genetic involvement .
Suggested the following five factors that he
believed controls growth.
1. Intrinsic genetic factor.
2. Local epigenetic factor.
3. General epigenetic factor.
4. Local environmental factor.
5. General environmental factor.
 Growth of the cranium
Cranial vault ( calvaria )
Cranial base ( basicranium )

Growth of the Nasomaxillary

complex.

Growth of the mandible

 Cranial vault is the part of the skull which surrounds
the brain.

Its made of number of flat bones which are formed

by Intramembranous bone formation.
Frontal bone

Two parietal bones

Squamous part of temporal

Squamous part of occipital bone

These bones articulates with each other at sutures

which at birth are not yet united
 Function:
The primary function of the bony cranial vault is
protection of the brain. Therefore, the vault
growth is paced by the growth of the brain itself
Timing
Since cranial vault surrounds and protects brain,
so it follows the neural growth pattern
The rate of bone growth is more during infancy
and by the fifth year of life; more than 90% of
growth of cranial vault is achieved.
So, cranial vault is one of the first regions of the
skull to achieve full size
 Mechanism
Sutural growth
Cranial vault consists of number of flat bones which
articulate with each other at sutures
At birth, these sutures are not yet united
As brain expands, the separate bones of the calvaria
are correspondingly displaced in outward direction
separating all of the bones at their sutural
articulations.
This displacement causes tension in the sutural
membrane which responds by depositing new bone
on the sutural edges
 Mechanism
Sutural growth
Growth at coronal and lambdoid sutures causes
increase in anteroposterior dimension

Growth at sagittal suture causes increase in lateral

dimension
 Mechanism:
Sutural growth
 Deposition and resorption

Apposition occurs on both the

external and internal tables of
cranial bones causing increase in
thickness

Some selective resorption occurs

on the inner surface of the cranial
bones to help flatten them out as
they expand
FONATANELLES
At birth ,skull bones are separated by loose
connective tissue.
6 in number.
Close at various times 2 months to 2 years
 The cranial base is made up of a midline base and
three cranial fossae

Function:
Supports and protects brain and spinal cord
Articulate the skull with the vertebral column,
mandible, and maxillary region
Buffer zone between the brain, face & pharyngeal
region.
 Mechanisms:
Bones of the cranial base are formed initially in
cartilage and are later transformed by endochondral
ossification to bone.

As ossification proceeds, bands of cartilage called

synchondrosis remain between centers of ossification
which are important growth sites
 Mechanisms:
Synchondrosis
Bands of cartilage which remain between centers
of ossification or remains of the primary
cartilaginous skeleton of the cranial base
They form important growth sites in the base of
the skull
N.B. sutures of the base of the skull are called
synchondrosis because they are of endochondral
origin
Synchondrosis Description Age of fusion

Inter-sphenoidal Between two parts of sphenoid bone At birth

Inter-occipital Between two parts of occipital bone 3-5 years

Spheno-ethmoidal Between sphenoid and ethmoid bones 7-10 years

Spheno-occipital Between sphenoid and occipital bones 20 years

 Mechanisms:
Remodeling
Enlargement of the cranial fossae is accompanied by
direct remodeling involving deposition on the
outside with resorption from the inside
 At birth:
The mandible appears to be as
a curved bar of bone,
The body is ill defined,
The rami are proportionally
short
And the condyles havent yet
become well developed.
Growth in the first year
The growth of the mandible in the first year of
life involves growth at the symphyseal suture
and lateral expansion in the anterior region to
accommodate the erupting anterior teeth.

There is increased deposition in the posterior

surface of the ramus of the mandible.
Mandible in adult
The mandible in adult is different from that in
infant.
The ramus is longer and the gonial angle is less
obtuse.
The bone is larger on the whole and the
condyle is well developed.
The mandible which is often retrognathic in
the newborn, assumes an orthognathic relation
with the maxilla during adulthood due to the
growth of bone in length
 Length
The growth of the mandible in length in anteroposterior
direction is by:
Deposition of bone at the posterior surface of the
ramus and resorption at the anterior surface.
 Length
The growth of the mandible in length in anteroposterior
direction is by:
The mandibular condyle grows in a posterior
superior and lateral direction through a process of
endochondral bone formation.
 Length
The growth of the mandible in length in anteroposterior
direction is by:
As the mandible grows posteriorly, it is displaced anteriorly
because the articulation of the condyle to the glenoid fossa is
constant and the change in length can take place only by the
anterior displacement.
 Length
The growth of the mandible in length in anteroposterior
direction is by:
The mental foramen during the early years of life is situated
under the mesial cusp of the first deciduous molar. In the
adult, it lies below and between the first and second
premolars.
 Length
The growth of the mandible in length in anteroposterior
direction is by:
There is corresponding surface remodeling at the anterior
border of the symphysis ( resorption in the superior part of
the anterior surface - above the mental protuberance - and
deposition in the inferior aspect.
This results in a protruding chin.
 Length
The growth of the mandible in length in anteroposterior
direction is by:
The angle of the mandible is augmented by addition of bone
to the posterior border of the ramus as a result, the angle of
the mandible decreases from 175 degrees at birth to 115
degrees in adult.
 Width
There is deposition in the lateral surface of the ramus and
resorption on the lingual surface
In contrast the coronoid process undergoes apposition at the
medial surface and resorption at the lateral surface. This
expands the mandible like a V
Thus the inter-ramal distance is efficiently increased, This helps
the mandible to keep pace with the growth of the cranial base.
 Width
 Width
 Height
The ramus increases significantly in vertical dimension to
accommodate the marked downward growth of the
nasomaxillary complex as well as eruption of teeth
Alveolar process growth along the superior border of the
mandibular body brings about an increase in the vertical
dimension
Bone deposition taking place in the lower border of mandible
also contributes to increase in the height of the mandible
 The middle third of the face is a complex structure
and includes maxilla, palate, zygomatic, ethmoid,
vomer and nasal bones.
These bones articulate with each other and with
cranial base at sutures
 Mechanisms and sites

Cranial base growth

Since the maxilla is attached to the
anterior cranial base, lengthening of
the cranial base pushes it forward.
Up until about age 6, displacement
from the cranial base growth is an
important part of the maxilla
forward growth

Failure of the cranial base to lengthen

normally as in achondroplasia, creates
a characteristic midface deficiency
 Mechanisms and sites
Cranial base growth
At about age 7, sutural growth is the only mechanism for
bringing the maxilla forward
 Mechanisms and sites
Sutures
The nasomaxillary complex is connected to the cranial base by
means of six pairs of sutures.
They are the most important sites of sutural growth.
These sutures are
Frontomaxillary

Zygomaticotemporal

Zygomaticofrontal

Zygomaticomaxillary

Frontonasal

Ptergopalatine
 Mechanisms and sites
Sutures
Suture attaching the maxilla posteriorly and superiorly are
ideally situated to allow its downward and forward
repositioning
 Mechanisms and sites
Deposition and resorption
Bone is added in the tuberosity region
creating an additional space into which
the primary and then the permanent
molar teeth successively erupt
As maxilla grows downward and
forward, bone is removed from the
anterior surface in order to maintain
concave contours beneath the pyriform
fossa and zygomatic buttress
i.e. surface remodeling of bone occurs in
opposite direction to that in which its
being translated by growth of adjacent
structure
 Mechanisms and sites
Deposition and resorption
In palate, bone is removed on the nasal side and added
on the oral side creating an additional downward and
forward movement of the palate

Alveolar process grows downward, outward and

forward increasing the alveolar height as the deciduous
and permanent teeth form and erupt
Anterior part of the alveolar process is a resorptive area so
removal of bone from the surface tends to cancel some of
the forward growth that otherwise would occur because
of the translation of the entire maxilla
 Mechanisms and sites
Nasal septum
The growth of the cartilaginous part of the nasal
septum is regarded as a source of the force that
displaces the maxilla downward and forward
 In fetal life (3MIU): head constitutes 50% of the
total body length, the cranium is large and
limbs are rudimentary

At birth: head constitutes 25-30% and legs

constitute 1/3 of the total body length

In adult: head constitutes 12% and legs of the

total body length
Growth spurts
This uneven or sudden activity of growth site
This is called growth spurts or growth peaks.
Types of growth spurs:
Name of spurt female Male

Childhood (infant) 3 ys 3 ys

Juvenile(mixed dentition) 6-7 7-9

Prepubertal(adolescent) 11-12 13-15

Clinical significance of the growth spurts
Treatment of skeletal discrepancies is more
advantageous if carried out during growth spurt.

Orthognathic surgery should be carried out after growth

ceases.