5 Postnatal Growth of The Craniofacial Region Reviewer

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 This remodelling occurs on both the outer (periosteal) and inner

Postnatal growth of the Craniofacial (endosteal) surfaces of each bone and the relocation, or cortical drift,
will follow the direction of external bony deposition.
Region
 The mandible does not
Human Skull grow by a simple
 twenty-two(22) bones symmetrical
enlargement.
Neurocranium (8)
 (8 cranial bones)

Ethmoid (1) Unpaired  Rather the condyle and


Sphenoid (1) Unpaired ramus elongate in a
Frontal (1) Unpaired posterior and superior
Parietal (2) Paired direction, whilst the
Temporal (2) Paired body of the mandible
Occipital (1) Unpaired lengthen.

Facial skeleton (14)


 (14 bones facial
bones)
Lacrimal (2) Paired
Nasal (2) Paired
Palatine (2) Paired
Inferior nasal concha (2) Paired
Vomer (1) Unpaired
Zygomatic (2) Paired
Maxilla (2) Paired
 Periosteal resorption ( – ) and deposition ( + ) on the external and
Mandible (1) Unpaired
internal surfaces of a skull bone can produce differential changes in both
size and shape, or relocation.
The skull at birth
 Displacement is mediated by the soft tissues, which apply external forces
 One of the most striking features of a newborn child is the large size of
upon the bones, resulting in their displacement away from each other.
the head in relation to the rest of the body
 This is because at birth, the cranial vault is approximately two-
thirds of its final dimension, due to extensive prenatal growth
and development of the brain. Theories of craniofacial growth
 The face of the infant skull is disproportionately small because the nasal
cavity, maxilla and mandible are all poorly developed. 1. Remodelling theory
 All of the individual bones within the neonatal skull are smaller than  James Couper Brash
those in the adult, with the exception of the ear ossicles.  Anatomist
 Six fontanelles or fibrous membranes are present in the neonatal skull.  This theory placed great emphasis upon remodelling as the primary
 These regions give a degree of fl exibility to the skull as it passes mechanism by which all bones within the craniofacial complex grew.
down the birth canal and are all closed by 18 months of age
 Thus, the cranial vault expanded via external deposition and internal
 Additional sutures are present in the neonatal skull, including the resorption, whilst the facial bones grew downwards and forwards relative
metopic suture within the frontal bone (closes at 7 years) and to the cranial vault by posterior resorption and anterior deposition.
symphyseal within the mandible (closes at 2 years).
2. Sutural theory
 Spheno-occipital synchondrosis  Joseph Weinmann and Harry Sicher
 is a cartilaginous growth plate present between the basilar region  two anatomists
of the occipital bone and the body of the sphenoid.  Suggested that primary growth of the craniofacial skeleton was
 This region is a significant growth centre, which persists until the genetically regulated, being controlled within the sutures and cartilages.
end of the second decade.
3. Cartilaginous theory
Mechanisms of craniofacial bone growth  James Scott
 Endochondral bone growth occurs through cartilaginous replacement,  Anatomist
whilst intramembranous bones grow as a result of periosteal  suggested that sutures simply represented a continuation of the
remodelling. periosteum and endosteum of the craniofacial bones, in modified regions
at their points of intersection.
 The basic mechanisms underlying growth of the craniofacial region  Growth in these regions should therefore be considered as periosteal in
reflect this and produce: nature, being permissive rather than producing a tissue-separating force.
 Relocation; and
 Displacement of individual bones.

 The relocation of a bone takes place via differential changes in both size
and shape, which are mediated by surface deposition and resorption.
4. Functional matrix theory  Endochondral growth
 Melvin Moss  Surface remodelling
 describes bone growth within the craniofacial skeleton as being
infl uenced primarily by function. How much does the anterior cranial base grow?
 From the age of 5 through to 20 years, the distance from sella to nasion
 Functional matrix will increase approximately 8-mm in females and 10-mm in males, with
 represents all the tissues, organs and spaces that perform a given this growth being essentially complete by the age of 14 and 17 years,
function, whilst skeletal units are the bones, cartilages and respectively.
tendons that support this function.
 Two types of functional matrix exist:
 Periosteal matrices; and  The sphenoethmoidal and sphenooccipital synchondroses make the
 Capsular matrices. most significant contributions to postnatal growth of the cranial base.
 The sphenoethmoidal synchondrosis is usually ossified at around 7 years
 Periosteal matrix of age.
 consists of the soft tissues intimately related to a skeletal unit,  The sphenooccipital synchondrosis persists for longer.
such as muscles and tendons; whilst capsular matrices are the  Direct histological examination of autopsy material suggests that in
organs and tissue spaces associated with specific regions within females it closes around 13 – 15 years of age, whilst in males it remains
the skull, such as the neurocranium, orbits and oropharynx. patent until 15 – 17 years.
 Skeletal units are also further subdivided into:
 Microskeletal units; and
 Macroskeletal units. Growth of the nasomaxillary complex

 Nasomaxillary complex
5. Servosystem theory  forms the middle part of the facial skeleton and is dominated by
 Alexandre Petrovic the orbits, nasal cavity, upper jaw and zygomatic processes.
 The primary cartilaginous skeleton of the craniofacial region is not
influenced by the local and systemic environment to the extent that  A number of bones make contributions to this region, including the
secondary cartilage of the mandibular condyle is. frontal, sphenoid, zygomatic, lacrimal, nasal, maxillary, palatine,
 Based upon these observations, he proposed that two principle ethmoid and vomer.
factors determine growth of the craniofacial region:
 Genetically regulated growth of the primary cartilages  The maxilla grows downwards and forwards in relation to the anterior
within the cranial base and nasal septum determine growth cranial base, accompanied by the orbits and nasal cavity, with all three
of the midface and provide a constantly changing reference regions increasing in volume as they grow.
input, which is mediated via the dental occlusion; and
 The mandible is able to respond to this changing occlusal
reference by muscular adaptation and locally induced
Growth of the mandible
condylar growth.
 The mandible also grows downwards and forwards in relation to the
cranial base and this is achieved by:
Growth of the cranial vault  Bony remodelling via subperiosteal resorption and deposition; and
 Cartilaginous growth at the condyle.
 Cranial vault
 is composed of the squamous parts of the frontal, temporal and  The ramus is remodelled in posterior, superior and lateral directions by
occipital bones, and the paired parietal bones. bony resorption and deposition.

 Growth of the cranial vault is intimately linked with growth and  The condyle is also a major site of growth within the mandible.
expansion of the brain, which passively displaces the individual bones of
the skull vault in a concentric manner. Condylar cartilage
 As this displacement takes place, the intramembranous bones of the  is a secondary cartilage that forms within the mandibular condyle at
cranium grow in two ways: around 10 weeks of embryonic development.
 Compensatory bone growth at the sutures; and  Initially, it forms a large carrot-shaped wedge within the whole of
 Surface periosteal and endosteal remodelling. the condyle, but progressive ossification during early postnatal life
results in a small cap of proliferating cartilage remaining beneath
the fibrous articular surface of the condyle until around the end of
 Sutures the second decade.
 are specialized fibrous joints situated between adjacent
intramembranous bones and they mediate growth along the
osteogenic fronts of these bones as they are displaced away from
How does the condylar cartilage differ from an epiphyseal growth
each other.
 Sutures are tension-adapted; they do not generate the forces plate?
underlying bone displacement, but respond to them, adding new bone
in equilibrium with bony separation and therefore maintaining patency.

Growth of the cranial base


 The cranial base develops from a primary cartilagenous
chondrocranium, which undergoes a programme of endochondral
ossification that is well advanced at birth.
 A number of bones contribute to the cranial base, including the frontal,
ethmoid, sphenoid and occipital.
 Postnatal growth of this region is achieved by the following
mechanisms:
 The condylar cartilage is concerned with maintaining growth of an Backward rotator.
intramembranous bone (the mandible) within a field of multidirectional
compression (the temporomandibular joint).
 Epiphyseal growth plates are found within long bones and facilitate
their elongation by endochondral ossification. Bone formation takes
place within the peripheral calicified zone of the cartilage and growth is
mediated by chondrocyte proliferation and cartilaginous replacement.

 Centres of rotation
Mandibular growth rotations are marked (X).
 Growth in length of the mandibular ramus occurs essentially at the
condyles, but this growth is variable in direction and often involves a
component of rotation
 Forward rotations are the most common, associated with centres of
3(Three) different types of mandibular growth rotation rotation through the condyles, incisors or premolars
 Backward rotations take place through centres in the condyles or the
1. Total rotation most distal-occluding molars.
 represents a change in inclination of the body or corpus of the Dentoalveolar compensation
mandible relative to the anterior cranial base.  A considerable amount of individual variation exists in the amount and
 The body is represented by a reference line constructed along the direction of maxillary and mandibular growth that occurs during
implants, or by natural reference structures present within this region. postnatal development.
 the sum of the matrix and intramatrix rotations  The dentoalveolar compensatory mechanism attempts to maintain a
normal interarch occlusal relationship in the presence of variation in the
2. Matrix rotation skeletal pattern.
 represents a change in inclination of the soft tissue matrix of the
mandible in relation to the anterior cranial base. A number of different factors are responsible for dentoalveolar adaptation:
 A line drawn tangent to the lower border of the mandible represents  Normal mechanisms of tooth eruption;
the soft tissue matrix and the condyles lie at the centre of this rotation.  Soft tissues forces; and
 Occlusal forces and mesial drift.
3. Intramatrix rotation
 is the difference between the total and matrix rotations if the Adult craniofacial growth
mandibular body rotates within the soft tissue matrix.  Although most craniofacial growth is complete by the end of
 This difference reflects bony remodelling that takes place along the adolescence, longitudinal studies have demonstrated that a small amount
lower border of the mandible and is defined by the change in inclination continues during adult life.
seen between an implant reference line and the mandibular lower  This tends to initially reflect the original growth pattern, especially when
border. there is an underlying skeletal discrepancy; however, later in adult life,
changes in the vertical dimension predominate.
 True rotation
 was used to represent a total rotation.
 is the fundamental rotation that takes place between the
mandible and cranial base

 Apparent rotation
 Apparent rotation of the mandible represented a matrix rotation.
 is the result of true rotation and remodelling of the mandibular
lower border and is the change apparent on a cephalometric
radiograph in the absence of implants.

 Angular remodelling of the mandibular border represented an


intramatrix rotation.
 The angular remodelling can only be visualized when the mandible is
registered on implants or stable structures.

Mandibular growth rotations


Forward rotator.

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