CROWTlI

AT FACIAli

SITTURES

INTRODUCTIOS

THE: present much being A T and patterns oftimegrowth inwork ishuman the

carried out on the methods, sites, face.l+ j This knowledge is of fundamental importance in the understanding of the etiology of malocclusions and facial deformities. Certain conclusions, however, are of doubtful validity. as they appear to bc based on an inadequate study of the mrthods of suture growth and the precise arrangements of the sutures in the facial skeleton. It, is the purpose of this article to investigate and discuss these matters.
GROMTH AT SUTURES

The structure of growing and adult sutures has been described by Pritchard and his associates. They have shown that a typical facial suture (Fig. 1) is composed of five layers of tissue between the bony margins of the sut)urc. These la.yrrs arc : .I. A cellular layer belonging to each bony unit. 2. A fibrous le,ycr continuous with the fibrous p,eriostrum covering each bone. 3. L4 central layer, containing blood vrsscls and unitiIkg strands of collagcnous fibers. Growth at a suture takes place at. each of the cc>llular (cambial) layers and may differ in its intensity and amount for each of the bones. The relationship of the bones to one another, at a suture may be (1) an edge-to-edge relationship (Fig. 2) or (2) an overlapping relationship (Pig. 3). If the relationship is of the edge-to-edge variety, growth at t,hc sut,ure is correlated with separation of the bony elements. Growth may take pla.cc at t,he sutural surface of one or the other of the bones or at both. The process may or may not involve a change in position of the suture (Fig. 2). Tt is important, moreover, to know whether or not. the suture changes position, as WItain sutures or points on sutures arc often taken as fixed points in superimposing ccphalograms in serial studirs of facial growth. Tf, howevrr, the rclat,ionship is of thr overlapping variety, growth at, the suture ncc~l not involve scparat,ion of the bones. With surface deposition, one boric migtxtrs over the surfacc~ of t,hc other and the position of the snt,urc
From the Anatomy Deuarhnent, Queens University. 381

.I.

II.

s~:oII

3 ----1 DD
A, 0. c.
q------w-w1 Q

D.

E.

shows new bone (lcpoaition. Wig. Z.--C:rowth at an cdgc:.to-mlge suture : <aross-hatclling h, Bone is deposited at each sutural clement: tlw bones move apart but position of the suture remains unaltered. C? and D, Bone is deposited at one or the other of bony elements and 0x1~ deposited at one bonr of the bones moves so that position of the suture is altcred. H. ~onc only, upper bone is fixed and lowrr bone moves ~lomnward whilfl position of suture rnnains unaltere(l.

Fig. S.--Growth at an overlapping suture. Wit11 cleposition of bone on not in the suture. one bone migrates upward over the surface of the other position of the suture is altcred. 1. (kipinul position : 3. na9v Ilosition.

the and

surface. but thr, suvfacr

tt1v

C:lW\\;th at SntUrYS does llot in itsdf produce sep:Wation of t,he bones at This is brought, about by the growth of other organs snc>h as t,hc (*;\rtilagc ot the chondrocr~anial and chontlrofacial skclcton, the l,rain, the cyclmlls, and t,hc tongues
sntuw.

The snturcs of the craniofacial skeleton can hc grouped into a numhcr of systms. The sntnpcs making ~1) each syst,elll are SO arranged ibs to pclrnrit growth in a certain direction. lhc suture systems in t,he human fac:cs
sntut~c 2l.W :

1. The sagittal sutu~ system, made up of the mid-palatal, intermaxillary, internasal, and metopic sutures with the mandibular symphysis. It is co111l)lc~tc in fctal lift and at birth, and permits growth in width of the facial skclcton. At the end of the first year. the tnandibular symphysis and the metopic~ srIt,ut*chin the ma,jority of persons have united. and the sagitt,al sutnrc systelrl is no longer complctc. It is donhtfnl whcthcr :rny further growth takes place in the mitl-palatal suture after this time. By the end of the first, yea I*, the distitllcc l)vtwcvn the Iwo orbital caritics across t,hc bridge of th(h K~OSC has ~a~hc~l nctnlt tlimcnsions in nmny children.

Fig. 4.--Uiagram to show the position of the maxillary and craniofacial suture Sotr relationships of frontomaxillary to the frontonssal suture and of the posterior N, Nasai bone : E, ethmoid of the maxilla to the palatine bone and pterygoid plates. process of maxilla. Illate) ; N, sphenoid (including pterynoid plates) ; Z, zygomatic

systems. border (orbita

2. !Zhe mazillar~ slstuye system, macle up of the sutnrrs separating the t~~;lxiIla from the nasal, frontal, lacrimal, facial cthmoitl, palatine, zygomatica, ant1 ~~omcr bones (Fig. 4). This system consists of two limbs, a horizontal ]ilrlb at the medial and lateral walls of the orbital cavity (including the votrrerine-maxillary junction of the nasal septum), and a vertical limb in the ptcrygopalatine fossa (hetwcen t,he maxillary and palatine bones). and 3. The cmn.iofacial s&we s@em, made up of the supramaxilla.ry 18~1 ro~naxillary facial bonc~s on one side (nasal, lacrimal, facial et,hmoid, pa1;1-

Of llll,

ItlilXillit.

Fig. 5.-Diagmrn to show the position of the zygornatic the maxilla BS seen in a transverse section. Arrow indiratrs the direction of growth of the maxilla in early childhood. Plate) ; Pt., pterygoid lrlates : %u~I.. zyaornatic bone.

and palatine bones retativc to position of nasal septum and Pal., Lalatinc bone (vertical

big. 5 shows in ii tlina.t;ttttttt;tt,iC ntantt(t the relationship of the palatine :lntl zygotnatic bones to the tnasilln its SCW~ a horizontal (transvcrsc) stdion itt of the t&c. .It will 1,~ SPOIL that the v~rtid plittc of the palatine l.)on(~,which fottlts part of th(a sick wall of the nas;tl cavity, OY(~~IRPS back part of the the nasal SLU+:MZ of the ttlitdll:t. Ihc two overlapping l~oncs bctwecrt them form t,ho boundaries of the grciltct palatine canal I(1ittlitlg frortl the l,tct.ygop,?Intillc fossa above to the greater palntinc foramcn on the palate bc~low. The zypotnatic hone nrt~iculatzs with the snrfacc~ of the zygomatic princess of the mnsilln which facts natww.rd and slightly forwit rd.

Fig.

R.-Wontonasal Note

the

and frontonmxillary higher position

of

sutures in a the frontonasal

child

of suture

6 years in the

and adult.

in

an

aclult.

tll(

Itct\v(~(~ll the ttasitl ittttl ft*otttill I)OI~CS is /tOtltOlttil~illi~~~ Slltllrt. Ih(s sutl~t*~~ :ISWII~~S 011 the ft*otttitl It(ttl(J with ;lg~. 01 thcl ctvc~rlapping nt riety antI ItilSiOtl This cillt lte sho~~t ils ~OIIOWS : I. Nasion is usl~itlly closcbt* to thtx llppct* ot*bit;~l tttittgitl itI ttdlllt, ~l<nll~ th:rn in tht ~l<lllI~ of childtm. 2. The ftY~lltOll~lSill SlltlltT iii ildllItS is llSll~lIl~ :lt, Lt highct 1~~1 than thtb frontotnasilla ty sutnrc. In cdhiltlt-cn! the t\v(l sutures ilr(l ;tt ith(tl~t the satllc ICVCI (+ig. 6). ::. Iii sagittal
is Sppn to

Sertions, the direction oi the frontortasal sutllW ~~]~\\ritt(IillIt OUt\V;llYl for SOlllC cliStilll(~(! hein tllc, iltllllt is llSll;lll~ SOIIIC foty it ~.lltms fot*w;t rtl. N;lSiOll t]ist,;l.tl(~c~ ;ll)o\(~ thtl Icv(~I of thta rtlt)f OC the lla~al cavity In cahil(lt*cn it, is at almut the siltttt: (etil)riEortt1 plntc). lovcl (Fig. 7).
11111

Therefore, the position of nasion cannot be taken as evidcncc of separation of the maxillary and frontal bones and it must be used with care as a fixed point in the superimposition of serial ccphalograms. Investigators sometimes treat changes at the posterior surface of t,hc maxilla as seen in lateral cephalograms as evidence of sutural growth. Diatnond4 pointed out that the posterior surface of the maxilla grows into the pt,erygopalatine fossa throughout childhood and adolescence and does not become buttressed against the pterygoid processes until adulthood. Furthcrmore, the alveolar bulb of the maxilla projects backward on the outer side 01 the lateral pterygoid plate and undergoes a p~~ccss of altc~rnating cxpatlsinn and contraction as the molar t&h develop within it and move forwaI,tl into

Big. I.--Diagram of a sagittal section through the upward migration of nasion relative to the roof frontal bone; E, ethmoid ; Na, nasion.

the front of the nasal of the nasal cavity. N,

cavity Nasal

to sho\r bone; F.

occlusion.7 necessarily sutures.

Therefore, growth at the posterior border of the maxilla dock not involve growth at the deeper palatomasillary or palat,opt,erypoid

Each suture has two growth sites, one for each of the bony elements. Growth at a suture may or may not involve a change in position of the suture and may or may not involve separation of the bones. During early childhood the maxilla is thrust downward and forward from the anterior segment. of the cranial base, but this process of bodily moremcnt of the boric is not brought about by growth in the sutures. The separating force is provided by growth of the septal cartilage and the orbital contents. The position of nasion and the posterior border of the maxilla, as seen in lateral cephalograms, cannot be used as direct evidence of sut,ure growth with scpn.t*ntion of t,hr bones in the analysis of growth chnngcs in the maxilla.
REFERENCES 1. Hjiirk, A.: odontol. Facial Growth in Man Studiell scandinav. 13: Y-31, 1955. With the Aid of Metallic Implants, Acts,

Additional

Reference

List

The following references should be atNed to the ;Lrticlr entitlrtl Care ol the Deciduous Teeth as t,he Basis of Occlusion of the Permanent Dentition by l~curnan 11. Laugh (AK J. ORTHODONTICS 41: 90-106, February, 1955) :
Rogers, Rogers, Rogws, Rogers, ,\lershon, hlrr~hon, .\lershon, ,\Iershon, ,Ylf red P. : Exercises for the Development of the llluscles of the Face, With a Viclw Dental Cosmos 60: 857-876, 191N. to Increasing Their Functional Activity, Increased Function in Treatment of Dental Anomalies, INT. .J. OWIIOAlfred P.: IKlNl'IA 15: 731-742, 1929. Alfrerl P. : The Place of Myofunctional Treatnwnt in the Correction of Itlalowlusion, CT. Am. Dent. A. 23: 66-78, 1Y:IR. Evolution, I)evelopment, ant1 Application of Rlyofunctional Thrrap!~ Alfred P.: in Orthodontics, Am. .T. Orthoilontics and Oral Surg. 23: 462-481, 1937. Facial Changes, Symposium, Dental (osmos 77: 1068-1079, 19%. .lohn V.: Why the Lingual Arch Is Applicable to the Orthodontic Irol~le~n, n. .Tohn V.: Record 46: 297, 192fi. The Removal-)le Lingual Arch Appliance, IiYT. J. ~RTHOlltlKlIA 12: Sohn V.: 1002-1026, 1926. Failures, TKT. .J. OI<~aOI>OIGlIz\ 22: 338-343, 1936. John V.: