1 The Development and Growth of The Face

Definitions
DEVELOPMENT addresses the progressive

evolution of a tissue. The ameloblasts develop
from less specific ectodermal tissue.
The development and Odontoblasts derive from young mesenchymal
growth of the face tissue.
DEVELOPMENT will be used to refer to an

increase in complexity, specialization.
Development is physiologic and behavioral
phenomenon. It is expressed by qualitative
Agnieszka Pernak, D.D.S. measure (harder).
2
Agnieszka Pernak, D.D.S.
Sequence of development from genes to fetus

The developmental ontogeny of the craniofacial
stomatognatic complex depends on:
1. Genetic factors like
inherited genotype
expression of genetic mechanisms
2. Environmental factors like
nutritional and biochemical interactions
physical phenomena
pressures
hydration, ect.
3. Functional factors like
muscle actions
growth expansion
atrophic attenuation
3 4
Agnieszka Pernak, D.D.S. Agnieszka Pernak, D.D.S.
Definitions GROWTH AT THE CELLULAR

GROWTH refers to an increase in size or LEVEL
number. It is mostly an anatomic phenomenon.
It is quantitively measured (longer, thicker). Hypertrophy - an increase in the size of individual
cells
GROWTH signifies an increase, expansion, or Hyperplasia - an increase in the number of the cells
extension of any given tissue. A tooth grows as
more enamel is deposited by ameloblasts. The Secretion of extracellular material - an increase in
size not related to the number or size of the cells
growth can be expressed by hypertrophy,
hyperplasia and secretion.
5 6
1
GROWTH AT THE TISSUE LEVEL Growth Pattern
PATTERN presents the physical
Interstitial growth - goes on everywhere within the arrangement and proportion of tissues and
tissues /at all points within the tissue/ (soft tissues)
parts of the body at any time. The overall
Surface apposition (hard tissues) - as the interstitial pattern of growth is a reflection of the growth
growth within mineralized masses is impossible , of the various tissues making up the whole
the bone is formed by apposition of new bone to organism.
free surfaces
Cephalocaudal gradient of growth is an axis
Bone remodeling - changes of the bone shape of increased growth extending from the head
through removal (resorption) of the bone in one
area and addition (apposition) of bone in another
toward the feet.
7 8
Cephalocaudal Gra
Gradi
dien
entt
Cephalocaudal gradient of growth is an axis of
increased growth extending from the head towards
the feet
basically
the parts of the body, that are further away from the
brain, tend to grow slower and longer, than those, Schematic representation of the changes in overall body proportions during
which are closer normal growth and development. After the third month of fetal life, the
proportion of total body size contributed by the head and face steadily declines.
(Redrawn from Robbins WJ et al: Growth, New Haven, 1928, Yale University
Press).
9 10
In the perspective of cephalocaudal gradient it is

obvious, that
the face grows slower and longer than the cranium,
Changes in proportions of the head and face during growth. At birth, the face the mandible grows slower but longer than the
and jaws are relatively underdeveloped compared with their extent in the adult. maxilla.
As a result, there is much more growth of facial than cranial structures
postnatally. (Redrawn from Lowery GH; Growth and development of children,
6th ed. Chicago, 1973, Mosby.)
11 12
2
Scammons curves for growth of the four major tissue systems of the body.
GROWTH PATERN In the normal growth pattern the

tissue systems of the body do not
grow at the same rate.
As the graph indicates, growth of

GROWTH VARIABILITY the neural tissues is nearly
complete by 6 or 7 years of age.
General body tissues, including
muscle, bone, and viscera, show an
S-shaped curve, with a definite
slowing of the rate of growth during
childhood and an acceleration at
GROWTH TIMING puberty.
6 7
13 14
15 16
Growth velocity curves for early

early--, average
average--, and late
late--maturing girls. Human Growth and Development
Although age is usually measured
in time
chronologically as the amount of PRENATAL
time since birth or conception, it is
also possible to measure age 0 2 weeks - the blastocyst
biologically, in terms of progress
toward various developmental 2 8 weeks - the embryo
markers or stages.
8 40 weeks - the fetus
This graph substitutes stage of
sexual development for chronologic
POSTNATAL
time to produce a biologic time scale 1 4 weeks - the neonate
and shows that the pattern is
expressed at different times 4 weeks 1 year - the infant
chronologically, but not at different
times physiologically. 1 3 years - the toddler
3 12 years - the child
12 19 years - the adolescent
17 18
3
Fetal growth and development during
DEVELOPMENT OF THE FACE pregnancy
AND THE OCCLUSION
intrauterine growth of the face and jaws

postnatal growth of the face and jaws
dental exchange and development of the occlusion
19 20
Fertilized Ovum
Fertilization
21 22
Zygote
23 24
4
Four-cell embryo
Two-cell embryo
25 26
Eight-cell embryo Morula
27 28
Blastocyst
Fetus at 8 weeks
1 Umbilical cord with hernia

2 Nose Telencephalon
3 Eye Diencephalon
4 Eyelid Mesencephalon
5 Ear (a: tragus, b: antitragus )
6 Mouth Metencephalon
7 Elbow Myelencephalon
8 Finger
9 Toes Spinal cord
10 Atrophied embryonic tail bud
29 30
5
THE FACE FORMATION All of five prominences and arches arise from neural
crest ectomesenchyme, that migrates from its initial
dorsal location into the facial and neck regions.
The face derives from five The two mandibular prominences derivatives from
prominences that surrounds a the first pair of sixth pharyngeal arches.
central depression, the
stomodeum , which is the Union of the facial prominences occurs by either of
future mouth. two developmental events at different locations
(between 4th and 8th week after conception)
merging of the frontonasal, maxillary and
mandibular prominences
Frontal aspect of the face of a 55--week embryo. fusion of the central maxilla-nasal
components.
31 32
The inter-maxillary segment of the upper jaw

(the pre-maxilla) in which the four upper incisors
Midline merging of the medial will develop, arises from the median primary palate,
nasal prominences forms the that is initially a widely separated pair of swellings
median tuberculum and of the merged medial nasal prominences.
philtrum of the upper lip, the
tip of the nose and the The lower jaw and the lip are simply formed by the
primary palate. paired mandibular prominences merging towards
the midline.
The merging of the lateral maxillary and mandibular

prominences creates the comissures (corners) of
the mouth.
33 34
The face formation Stages of Embryonic Craniofacial

Development
Time Related Syndromes
(humans - post- fertilization)
Day 17 Fetal alcohol syndrome (FAS)
Days 19 28 Hemifacial microsomia
Mandibulofacial dysostosis (Treacher
Collins syndrome)
Days 28 38 Limb Abnormalities
Cleft lip and/or palate, other facial clefts
Days 42 55 Cleft palate
Day 50 birth Achondroplasia
Synostosis syndromes (Crouzons,
Aperts, etc.)
35 36
6
Unilateral lip cleft : more common on the left side,
common congenital defect - 1 in 800 births.
During the 7th week post conception, Bilateral lip cleft

cleft: is due to medial nasal prominences'
a shift in the blood supply of the face failure to fuse with the maxillary prominence on either side
of the midline.
(the formation of internal to external carotid artery)
occurs as a result of normal atrophy of the Median lip cleft
cleft: is due to incomplete merging of the two
stapedial artery. medial nasal prominences (therefore leading in most
This shift occurs at a critical time of midface and cases to bifid nose).
palate development, providing the potential deficient Macrostomia: merging of the maxillary and mandibular
Macrostomia
blood supply and consequent defects of the upper lip prominences short of the site for normal mouth size.
and the palate. Microstomia: merging of the maxillary and mandibular
Microstomia
prominences beyond the site for normal mouth size.
Astomia: fusion of maxillary and mandibular prominences.
Astomia
37 38
FORMATION OF THE SECONDARY

Moreover, the mandible at that moment becomes
PALATE more prognatic (giving even more space for tongue to
The stomodeal chamber divides into separate oral and nasal descend), but maxillary width remains stable allowing
cavities when the frontonasal and maxillary prominences shelves contact to occur. The shelves elevate. The
develop horizontal extensions into the chamber (from 8 th to elevation of the shelves enables their mutual contact
12th week in uteri) in the midline and their contact with the primary
The coincidental development of the tongue from the floor of palate anteriorly and the nasal septum superiorly.
the mouth fills the oronasal chamber, intervening between the Fusion of the shelves, which starts a third of the way
lateral palatal shelves. These shelves are initially oriented from the front, proceeds both anteriorly and
vertically (downward), but become horizontaly oriented when posteriorly. The shelves also fuse with the nasal
the stomodeum expands and the intervening tongue
descends. The embryo's face removes from against the heart
septum, except posteriorly, where the soft palate and
prominence by the uprighting of the head, what enables jaw uvula remain unattached.
opening and the tongue descends from between palatal
shelves. 39 40
Methods for studying physical growth The Difference Between Physical

Growth and Psychological
Craniometry
Anthropometry
Development
Cephalometric radiology
Physical growth can be considered with the
outcome of an interaction between genetically
Three-dimensional imaging controlled cell proliferation and environmental
influences that modify the genetic program.
Psychological development can be observed

through cognitive (intellectual) and emotional
(individual) development.
41 42
7
In animals:
The Difference Between Physical
Growth and Psychological the majority of behaviors
Development (continues)
are instinctive.
Social and Behavioral development can be
considered as the result of an interaction
between inherited or instinctual behavior In humans:
patterns and behaviors learned after birth.
the majority of behaviors
are learned.
43 44
Eriksons stages of emotional development Cognitive development

Eriksons eight ages of man
Cognitive development is the development of intellectual capabilities
which can be divided into four major stages
Erikson claims that some adults never reach the final steps on the developmental staicase
45 46
Facial Growth
Facial Growth
A background in craniofacial growth and
development is essential in learning orthodontics.
Today there are many methods, which ables to
manipulate the facial growth for the benefit of the
patient.
It's not possible to do so without understanding of
the pattern of normal growth and it's mechanisms.
47 48
8
Changes from infancy to adulthood The neurocranium
is the fastest growing area
baby face
-Large eyes
of the craniofacial skeleton
-Dainty jaws at birth.
-Small pug nose
-Puffy cheeks
-High intellectual forehead
-Light eyebrows
-Small mouth
-Wide short proportions
= cute face
49 50
The face and jaws are relatively

underdeveloped. Therefore there is much Growth is a differential process
more facial growth than cranial growth i.e. different parts of the cranio-skeleton
postnatal undergo the process of growth at different
times, in different directions and involve
different but interdependent functions
Yet somehow an individual face maintains

its integrity
51 52
BONE FORMATION Sutural & Synchondrosal Remodelling

Sutural, synchondrosal and cartilaginous remodelling
are secondary to displacement
ENDOCHONDRAL OSSIFICATION - the bone has
the embryonic cartilaginous model, in which the
centers of ossification appear and where the
cartilage is transformed into bone
INTRAMEMBRANOUS BONE FORMATION - by

secretion of bone matrix directly within connective
tissues, without intermediate formation of cartilage
(cranial vault and both jaws)
53 54
9
In the intrauterine development at first cartilaginous/chondrocranium
forms. It is supplied by diffusion through the outer layers. As the brain INTRAMEMBRANOUS BONE
becomes bigger in fourth months in utero development there is an in
growth of blood vascular elements into chondrocranium because the FORMATION
diffusion is not sufficient anymore.
The mandible forms in the same area as the cartilage of first
These areas of in growth become centers of ossification, at which
cartilage is transformed into bone. Than the old chondrocranium forms pharyngeal arch (the Meckels cartilage) but a little bit lateral
only small areas of cartilage interposed between the large sections of to it, and undergoes an intramembranous bone formation.
the bone. The type of growth at these cartilaginous connections is (Meckels cartilage disappears and remnants of it form
similar to the growth in the limbs. In the long bones the areas of ossicles of the middle ear.) The condylar cartilage develops
ossification appear in the middle of the bones and at the ends: diaphysis initially as an independent secondary cartilage, and than it
and epiphysis. Between them a remaining area of uncalcified cartilage is fuses with the developing mandibular ramous.
called the epiphyseal plate, where the actively dividing cells mature and
secrete an extracellular matrix, which degenerates as the matrix
mineralizes to the bone. The growth occurs as long as the rate of The maxilla forms from a center of mesenchymal condensation
proliferating cells is equal to the rate of maturating cells. In the end of in the maxillary process.
growth the rate of maturation is bigger than the rate of proliferation and
the epiphyseal plate disappears.
55 56
CRANIAL VAULT
For a better understanding of growth it is
useful to divide the head into four areas is formed by intramembranous bone formation, without
with a different types of growth : cartilaginous precursors. The growth is the result of
periosteal activity at the surfaces of the bones in the cranial
cranial vault, sutures (growth) and on the inner and outer surfaces of the
bone (remodelling). At birth the wide sutures and
cranial base, fontanelles allow a deformation of the skull, when it passes
through the birth canal. After birth, apposition of the bone
naso
naso--maxillar complex, eliminates fontanelles quickly, but sutures are fusing after
mandible. the growth competition in adult life.
57 58
CRANIAL BASE Forward growth of the anterior cranial base
is formed by endochondral ossification in cartilage.

Early in embryonic life centers of ossification appear
in chondrocranium, and as the ossification proceeds
only bands of cartilage (synchondroses) remain
between them
Spheno-occipital synchondrosis
Intersphenoid synchondrosis
Spheno-ethmoidal synchondrosis
They look like two-sided epiphyseal plate.
59 60
10
Changes in cranial base deflection NASO-MAXILLAR COMPLEX
is formed by intramembranous ossification and is growing:
by bone apposition at the sutures, connecting the maxilla to the cranium
and cranial base. The growth occurs on both sides of a suture, so the bones
to which the maxilla is attached also become larger. As a consequence of
this the maxilla moves downward and forward (translation).
by bone apposition at the midpalatal suture, which ceases early between 1
and 2 years of age, but the suture completely fuses rather after 30 years of
age.
by surface remodeling
bone apposition at the tuberosity region (posterior border of the
maxilla), what creates the additional space for primary and
permanent molar teeth,
bone removal from the anterior surface (opposing effect to bone
translation),
bone apposition on the roof of the mouth (additional downward
Forward displacement of Downward displacement
movement of palate and enlargement of nasal cavity) + bone removal
mandible of mandible
from the floor of nasal cavity,
61 bone apposition on the lateral surfaces, which continues until 7 years
62 of
Agnieszka Pernak, D.D.S. age. Agnieszka Pernak, D.D.S.
The Growth Process 2. Displacement - a change in position

1. Remodeling - deposition and resorption
Remodeling of the palatal vault moves it

down. Bone is removed from the floor of
the nose and added to the roof of the
mouth.
63 64
Remodelling and displacement Displacement of the maxilla downward

of the naso-maxillary complex
65 66
11
MANDIBLE The Growth Process
is formed by endochondral and periosteal activity
cartilage on the surface of the mandibular condyle at the 1. Remodeling - deposition and resorption
TMJ
surface apposition and remodeling
syndesmosis in the midline becomes synostosis 4-12
month after birth
Growth in width is completed first, than growth in length , and

finally growth in height.
Growth in width tends to be completed before adolescent Mandibular growth reveal minimal
growth spurt. changes in the body and chin area, while
Growth in length and height continues through the period of there is exceptional growth and
remodeling of the ramous, moving it
puberty (in length in girls - 2 to 3 years after first
posteriorly.
menstruation; in height - to early twenties in boys).
67 68
2. Displacement - a change in position

Remodelling and displacement
The correct concept of the mandibular
of the mandible
growth is that the mandible is translated
downward and forward and growths
upward and backward in response to this
translation, maintaining its contact with
the skull.
As the mandible grows in length, the
ramus is extensively remodeled, so
much that bone at the tip of the
condylar process at an early age can be
found at the anterior surface of the
ramus some years later. Given the
extent of surface remodeling changes, it
is an obvious error to emphasize
endochondral bone formation at the
condyle as the major mechanism for
growth of the mandible.
69 70
Compensatory growth Compensatory growth
71 72
12
Rotational changes of the mandible
Positive
Rotation
Negative
Rotation
Bjork and Skieller 1983

73 74
Ricketts Superimposition - Basion

Basion--Nasion at CC Facial pattern in relation to the height, width and depth of the skull.
Identified a centre of growth of the face

CC point
Gnomic Growth
- the facial form remains constant
- unaltered facial growth is seen as

concentric patterns
Polar Axis
- skeletal landmarks grow away from

CC point in straight lines
- the more distant the landmark from

CC the more rapidly it grows away
75 76
Euryprosopic type Leptoprosopic type When the pattern of facial growth is known
orthodontic treatment can be optimised
It may be possible to reduce intervention and

length of treatment with correct timing
When natural growth can be predicted it

becomes possible to superimpose known
treatment response and estimate outcome
It also makes it possible to predict cases that are

unlikely to respond favourably and plan
alternative treatment e.g. surgery
77 78
13
Aberrations from normal growth
Dentoalveolar modifications
A few clinical cases
79 80
Changes in morphology with growth Absence of cartilaginous growth
Profile view of a man whose cartilaginous nasal septum was removed at age 8, after
81 an injury. The obvious midface deficiency developed after the septum was removed.
82
Hemifacial microsomia
Skeletal modifications - condylar fracture
External fixation for lengthening the mandible by distraction osteogenesis in

a child with hemifacial microsomia.
83 84
14
Ankylosis of the mandible following
infection Conclusion
Excellent orthodontic treatment relies on a

good understanding of natural growth and
development. As well as an understanding
of the ability of various mechanical
interventions to produce changes in the
craniofacial skeleton.
Profile view of a girl in whom a severe infection of the mastoid air cells involved
the temporomandibular joint and led to ankylosis of the mandible. The resulting
restriction of mandibular growth is apparent. 85 86
Thank you!
87
15

1 The Development and Growth of The Face

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Definitions

DEVELOPMENT addresses the progressive

DEVELOPMENT will be used to refer to an

Sequence of development from genes to fetus

Definitions GROWTH AT THE CELLULAR

In the perspective of cephalocaudal gradient it is

GROWTH PATERN In the normal growth pattern the

As the graph indicates, growth of

Growth velocity curves for early

intrauterine growth of the face and jaws

Eight-cell embryo Morula

1 Umbilical cord with hernia

The inter-maxillary segment of the upper jaw

The merging of the lateral maxillary and mandibular

The face formation Stages of Embryonic Craniofacial

During the 7th week post conception, Bilateral lip cleft

FORMATION OF THE SECONDARY

Methods for studying physical growth The Difference Between Physical

Psychological development can be observed

Eriksons stages of emotional development Cognitive development

The face and jaws are relatively

Yet somehow an individual face maintains

BONE FORMATION Sutural & Synchondrosal Remodelling

INTRAMEMBRANOUS BONE FORMATION - by

CRANIAL BASE Forward growth of the anterior cranial base

is formed by endochondral ossification in cartilage.

The Growth Process 2. Displacement - a change in position

Remodeling of the palatal vault moves it

Remodelling and displacement Displacement of the maxilla downward

Growth in width is completed first, than growth in length , and

2. Displacement - a change in position

Compensatory growth Compensatory growth

Bjork and Skieller 1983

Ricketts Superimposition - Basion

Identified a centre of growth of the face

- the facial form remains constant

- unaltered facial growth is seen as

- skeletal landmarks grow away from

- the more distant the landmark from

It may be possible to reduce intervention and

When natural growth can be predicted it

It also makes it possible to predict cases that are

A few clinical cases

Changes in morphology with growth Absence of cartilaginous growth

External fixation for lengthening the mandible by distraction osteogenesis in

Excellent orthodontic treatment relies on a

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