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GROWTH AND
DEVELOPMENT
PRE-NATAL & POST-NATAL GROWTH OF
MAXILLA AND MANDIBLE
CONTENTS
1)Pre Natal development of Maxilla
   Embryonic development
   Meckel’s cartilage
   Development of palate
   Mech’ of palate elevation
   Palate remodelling
2)Post Natal development of Maxilla
   Displacement
   Remodelling
   Growth at sutures
   Growth in height,wifth & length
   Key ridges
   Maxillary sinus
CONTENTS
1)   Pre Natal development of Mandible
2)   Post Natal development of Mandible
    Growth timing
    Sites of Growth
    Development of ramus,lingual tuberosity,condyle
    Growth by counterpart principle
    Ramus uprighting
    Age changes in Maxilla
    Age changes in mandible
    Developmental disturbances of face,lip,palate
    REFERENCES
PRE-NATAL DEVELOPMENT
OF MAXILLA
ANATOMY OF THE MAXILLA
PARTS OF MAXILLA.
  1. BODY –large and pyramidal in shape.


 2.   FOUR PROCESSES.
       Frontal
       Zygomatic
       Alveolar
       Palatine


 Maxilla houses the largest sinus of the face, the
   maxillary sinus
DEVELOPMENT OF MAXILLA


Maxilla forms within the maxillary prominences
  extending ventrally

  from the dorsal aspect of a much

  larger mandibular swelling.


Ossification of maxilla begins slightly later than in the
  mandible.
DEVELOPMENT OF MAXILLA
 The primary ossification centre appears for each maxilla
  in the 7th week.
 The secondary centers are at- zygomatic, nasopalatine
  and orbitonasal areas

   It lies in the angle formed by the infraorbital nerve and
    anterior superior alveolar nerve,above the part of the
    dental lamina from which the canine tooth germ
    develops.
DEVELOPMENT OF MAXILLA


   The premaxilla begins to ossify from two centres
    in the latter part of the 7th week.

   Ossification spreads by:
-   Bony trough formed for infraorbital nerve
-   Palatine process

   Maxillary sinus – 16th week
Around the 4th week of intra-uterine life,    the
developing brain and the pericardium form    two
prominent bulges on the ventral aspect of     the
embryo. These bulges are separated by         the
primitive oral cavity or stomatodeum.

  The floor of stomodeum is formed by the
buccopharyngeal membrane which separates it
from the foregut.

The pharyngeal arches are laid down on lateral
and ventral aspects of the cranial most part of
the foregut which lies in close approximation
with the stomodeum
   Initially, there are 6 pharyngeal
    arches, but the 5th one usually
    disappears as soon as it is formed
    leaving only five.


   They are seperated by 4 branchial
    grooves.


   The first arch is called
    MANDIBULAR ARCH and second
    arch is called HYOID ARCH.
MECKEL’S CARTILAGE

    It is derived from the first
    branchial arch around the
     41st – 45th day of intra-uterine
    life

   It extends from the cartilaginous otic capsule to the
    midline or symphysis and
      provides a template for guiding the growth of the
    mandible.
    A major portion of this cartilage disappears during
    growth and the remaining part develops into following
DEVELOPMENT OF PALATE
   Palatogenesis begins towards the end of 5th week and is
    completed by about 12th week.
   The palate develops from two primordia.
     Primary   palate
     Secondary   palate
PALATE

Primary palate
 At the end of 5th wk
 Develops from deep part of inter maxillary segment of
  the maxilla.
 Internal merging of medial nasal prominences.
 Represents only a small part of adult hard palate.
PALATE




Secondary palate
   Primordium of the hard and soft palate posterior to the
    incisive foramen.


   Begins to develop in the 6th wk, from shelf like
    structures called lateral palatine processes.
PALATE


   The tongue is initially
    interposed between the
    secondary palatal
    shelves.

   The palatal shelves
    become positioned
    above the tongue to allow
    for fusion in the midline.
PALATE
   The processes fuse in the midline and with the nasal
    septum and posterior part of primary palate.

   begins anteriorly during the 9th wk and is completed
    posteriorly by the 12th wk.
PALATE
   The posterior part of palatal processes remains
    unossified, they extend posteriorly beyond the nasal
    septum and fuse to form soft palate and uvula.
Formation of palate
MECHANISM OF PALATE ELEVATION




                Elevation of the palate
o   Descent of tongue influenced by the growth of the
    Meckel’s cartilage and mandible.
o   Myoneural activity in the tongue.
o   Mouth opening reflexes
MECHANISMS OF PALATE ELEVATION
INTRINSIC
   Hydration and polymerization of intracellular
    substances producing an elastic elevating force.


   Differential growth of one side of the palatal shelf.


   Triger produced by a build up mucopolysaccharides.


   Serotonin release from neural tissue.
PALATE
Genesis of cleft palate
o   Delay in shelf elevation
o   Disturbance in mechanism of shelf elevation
o   Failure of shelves to contact due to lack of growth
o   Failure to displace the tongue during closure
o        [Pierre robin syndrome]
o   Failure to fuse after contact as epithelium does not break
    down
o   Rupture after fusion
o   Defective merging
   The formation of the palate involves the coordinated outgrowth,
    elevation and midline fusion of bilateral shelves leading to the
    separation of the oral and nasal cavities.
   Reciprocal signaling between adjacent fields of epithelial and
    mesenchymal cells directs palatal shelf growth and
    morphogenesis.
   Loss of function mutations in genes encoding FGF ligands and
    receptors have demonstrated a critical role for FGF signaling in
    mediating these epithelial–mesenchymal interactions.
   Hence, deletion that removes the FGF signaling antagonist Spry2
    have cleft palate
PALATAL REMODELING
   External side of the anterior part of the maxillary
    arch is resorptive… with bone being added onto
    the inside of the arch…..increase in arch
    width…..increase in palatal width… V principle.


   Growth along mid palatal suture.
   As palate descends inferiorly….

    -   It occupies a different position
CLINICAL IMPLICATION
   In RME, remodeling of
    maxilla follows clinically
    induced displacement.

   lateral aspect of maxilla
    is resorptive.

   After fusion of mid
    palatal suture, increase
    in arch width is due to
    remodeling of the
    alveolar process.
INTER MAXILLARY SEGMENT




 It
   is composed of
   - a labial component : philtrum of upper lip
   -upper jaw component : carries four incisor
     teeth.
   - palatal component : that forms the
 triangular primary palate.
The intermaxillary segment is continuous with
 the rostral portion of the nasal septum which
 is formed by the frontal prominence.
POST NATAL GROWTH OF
MAXILLA
DEVELOPMENT OF MAXILLA
Growth occurs by:
 Apposition of bone

 Surface remodeling



Movement downward & forwards:
 Cranial base growth

 Growth at sutures
POST NATAL GROWTH OF MAXILLA:-


  Growth   of nasomaxillary complex is produced
   by following mechanism:-
  Displacement (translation ie acc’ to moss)

   :-leads to apposition of bone at sutures
  Surface remodeling(transposition)

                           apposition

                         resorption
DISPLACEMENT

   Primary displacement: the process of physical
    carry, takes place in conjunction with a bone’s
    own enlargement; joint contacts are important in
    this process.

   Secondary displacement: the movement of bone
    and its soft tissues is not directly related to its own
    enlargement .It is a fundamental part of the
    overall process of craniofacial enlargement
own enlargement   not directly related
 It is physical movement of bone.
 Causing secondary deposition of bone at sutures

 Downward and Forward growth
REMODELLING

  The functions of remodeling includes:
a) To progressively create the changing size of each
   whole bone
b) To sequentially relocate each of the component
   regions of the whole bone to allow for overall
   enlargement
Growth & development of maxilla and mandible
    As maxilla grows due to primary displacement its
    anterior surface tends to resorb as part of
    remodeling.
GROWTH AT SUTURE

The maxilla is connected to the
cranium and the cranial base by a
number of sutures.
These sutures include :
Fronto- nasal suture.
Fronto– maxillary suture.
Zygomatico– maxillary suture.
Pterygo– palatine suture.
Zygomatico – temporal suture.
POSTNATAL GROWTH OF MAXILLA
   Growth in height   -       vertical

   Growth in width    -       transverse

   Growth in length       -   A -P
TRANSVERSE DIMENSION (IN WIDTH)


   Growth in midpalatine suture

   remodelling at lateral surface of alveolar process
A-P DIMENSION(IN LENGTH)




  Maxillary    Palato       primary   secondary
tuberosity     -maxillary
               suture           displacement
VERTICAL DIMENSION (IN HEIGHT)




                     Eruption of      Primary
  Patatal
                        teeth      displacement
  remodelling
SECONDARY DISPLACEMENT OF NMC


   Expansion of Middle Cranial fossa has secondary
    displacement effect on anterior Cranial floor and
    thus on underlying NMC.

   Growth occurs in all the 3 dimensions
   A-P dimension(in length)
   Transverse dimension (in width)
   Transverse dimension (in width)
SECONDARY DISPLACEMENT
(TRANSVERSE DIMENSION)
   Left and right temporal lobes move away from
    each other

   Increase in transverse width of middle cranial
    fossa

 Increase in width of maxilla by-
 Growth in mid palatine suture

 Remodeling at lateral aspect of alveolar process
SECONDARY DISPLACEMENT
    (A-P DIMENSION)

Ant. & Middle cranial fossa move away from each
 other

NMC carried in forward direction

Bone deposited in tuberosity area

Increase in A-P dimension
SECONDARY DISPLACEMENT
(VERTICAL DIMENSION)
 Middle cranial base is in inclined plane

 Increase in dimension of Middle cranial base

causes displacement of NMC in downward
 direction
NASOMAXILLARY REMODELLING
   As clinically and biologically all inside and outside
    parts,region and surface participate directly in
    growth
   So key factors in NMC growth includes
•   Lacrimal suture
•   Maxillary Tuberosity
•   Vertical drift of teeth
•   Nasal airway
•   Palatal remodelling
•   Cheek bone & zygomatic arch
•   Orbital remodelling
LACRIMAL SUTURE
(KEY GROWTH MEDIATOR)
   Diminutive flakes of bony islands surrounded by
    many sutures forms perilacrimal sutural system

   Without it a developmental ‘gridlock’ will occur
    among differentially developing multiple bones
   It slides maxilla downward along its orbital contacts.This
    allows whole maxilla to get displaced inferiorly



   The lacrimal bone itself undergoes a remodeling rotation
    ,because the more medial superior part remains with the
    lesser expanding nasal bridge,while the more lateral
    inferior part moves markedly outward to keep pace with the
    greater expansion of the ethmoidal sinuses.
MAXILLARY TUBEROSITY
 The horizontal lengthening of the bony maxillary
  arch is produced by remodeling at the maxillary
  tuberosity
 Established by the posterior boundary of anterior
  cranial fossa
 It is a depository field

 the maxillary tuberosity is important in clinical
  orthodontics.it is also a major site of maxillary
  growth
 It lengthens posteriorly
MAXILLARY TUBEROSITY



              It lengthens posteriorly
                           A-P
              Deposits on buccal surface
                          width
              Deposits on alveolar ridge
                         height
KEY RIDGE
 Reversal lines occur at Key Ridge
 Anterior to it : Resorption

 Posterior to it: Apposition



* Reversal line: Irregular lines
  containing concavities directed
  away from the bundle bone and
  serving as histologic indications
  that resorption has taken place up
  to that line from the marrow side.
THE NASAL AIRWAY
   Lining surface of bony wall and floor

   Resorptive

   Lateral and anterior expansion of nasal
    chamber

   Downward relocation of palate

 The airway functions as a key stone for face
 Its obstruction can cause variation in facial
  skeleton
PALATAL REMODELING
 o Anteriorly - labial side is Resorptive
 oand palatal side is depository causes
 o widening of palate acc to V principle
 o As the palate grows inferiorly by the
 remodeling process, a nearly complete
 exchange of old for new hard and soft
 tissue occurs
 oGrowth at mid palatal suture plays a
 role in the progressive widening of the
 palate and alveolar arch
MAXILLARY SINUS
 All internal surfaces are resorptive except
  medial nasal wall
 Rapid continous downward growth

 Close proximity to buccal maxillary teeth
EXPANSION OF MAXILLARY SINUS

At birth   -   7 mm length
           -   4 mm height
           -   4 mm width
Expands at
rate of    -   2 mm vertically yearly
           -   3mm A-P yearly

Expansion by   - bone resorption
               - by tooth eruption
                 (as vacated bone become
                  pneumatized)
THE CHEEK BONE & ZYGOMATIC ARCH
 The growth changes of the malar
  complex are similar to those of maxilla
  itself
 The malar region and the anterior part of
  the zygoma undergo posterior
  remodeling movements.
 The inferior edge of the zygoma is
  heavily depository
 As the malar region grows and becomes
  relocated posteriorly, the nasal region is
  enlarging in an opposite,anterior
  direction,drawing out the nose and
  making face deeper,anteroposteriorly
ORBITAL GROWTH
   Follows ‘V’ principle



   Enlarging displacement occurs



   Growth at sutures



   orbital floor moves
VARIATION IN NMC GROWTH
 class II ( excessive mid face growth)
 class III (decreased midface growth)

 It’s common site for single most common
  craniofacial anamoly Cleft Palate
DEVELOPMENT OF
MANDIBLE
PRE NATAL GROWTH OF
MANDIBLE
DEVELOPMENT OF MANDIBLE
 2nd bone to ossify
 Intramembranous + endochondrial

 6th week of intrauterine life
   36-38th day mandibular ectomesenchyme interacts with
    mandibular epithelium before primary ossification.
   Intramembranous bone lies lateral to cartilage.
   First ossification centre for each half arises in 6th week in
    region of bifurcation of IAN into mental, the ossification
    spreads dorsally and ventrally to form ramus and body.
   Ossification stops at site where it would be lingula.
    Medially it meets its fellow counter part,distally upto
    middle ear.
   Major cartilage disappears.
   Secondary accessory cartilages occur bet 10-14th weeks
    to form head of condyle, coronoid,mental protuberence
   Coronoid cartilage: fuses with expanding
    intramembranous ramus before birth
   Mental:1-2 small cartilages appear and ossify in 7th
    month iu in fibrous symphysial tissue
   Condylar cartilage: appear 10th wk.
   this is promordium for future condyle.
   cartilage differentiate by interstitial n appositional
    growth.
   By 14th wk, 1st evidence of endochondral bone
    formtation
   Condyle cart is an imp growth centre for ramus.
   Condylar growth ia at its peak at puberty.
   Occurs12-14 months post natally,2halves fuse into
    synostosis
   Mandible appears as single bone.
   Basal bone forms one unit to with alveolar,
    condylar, coroniod, angular process and chin is
    attached.
   They grow by functional matrix theory
   Teeth act as functional matrix for development of
    alveolar bone
   Temporalis influences coroniod process
   Masseter n med pterygoid – at angle
   Lateral pterygoid – at condyle
POST NATAL GROWTH OF
MANDIBLE
POST NATAL GROWTH AND
DEVELOPMENT

GROWTH TIMING


Growth of width of mandible is completed first,
 then growth in length and finally growth in
 height
POST NATAL GROWTH AND
DEVELOPMENT

    WIDTH OF MANDIBLE
   Growth in width is completed before
    adolescent growth spurt
   Intercanine width does increase after 12 years
   Both molar and bicondylar width shows small
    increase until growth in length ends
POST NATAL GROWTH AND
DEVELOPMENT


    GROWTH IN LENGTH

 Growth    in length continues through puberty
    Girls—14-15 years
    boys---18-19 years
MAIN SITES OF POST NATAL GROWTH
IN THE MANDIBLE

   Condylar cartilage

   Posterior border of the Rami

   Alveolar ridges
CONDYLAR CARTILAGE

 Secondary cartilage
 Dual in function

  a) Articular
  b)Growth
 Not a primary centre for growth ,but

 Secondary in evolution

 Secondary in embryonic origin

 Secondary in adaptive responses to changing
  developments
DEVELOPMENT OF MANDIBLE



• Ramus
• Lingual tuberosity
• Condyle
Ramus
• It provides an attachment base for masticatory
  muscles.
• It positions the lower arch in occlusion with the
  upper.
• It is continuously adaptive to the multitude of
  changing craniofacial conditions.
   Moves progressively posterior by

   Deposition            Posterior part

   Resorption            Anterior part
   Superior part of ramus below sigmoid notch
                                Lingual : deposition



                     Buccal : Resorption
   Lower part of ramus below the Coronoid process

                                Buccal : depostion




                       Lingual : Resorption
Growth & development of maxilla and mandible
• The mandible as a whole displaces anteriorly
  and inferiorly.
• The former anterior part of the ramus becomes
  the corpus by resorptive and depository
  remodeling.
THE LINGUAL TUBEROSITY
 Major site of mandibular growth and remodeling.
 Direct anatomic equivalent of the maxillary
  tuberosity.
 Effective boundary between the basic structures-
  ramus and corpus.
 Grows posteriorly by deposits on the on its
  posterior surface
 Its prominence is augmented by the presence of a
  resorptive field below it, lingual fossa.




   Simultaneuosly the part of the ramus behind the
    tuberosity remodels medially
RAMUS TO CORPUS CONVERSION
 The anterior border of the ramus resorbs relocating
  the ramus in a posterior direction.
 Development takes place according to the ‘V’
  principle.
   Coronoid process- its lingual surface faces
                 posteriorly
                 superiorly
                 medially all at once.




    Deposits of bone on the lingual surface bring
    about growth superiorly, posteriorly and medially.
•   The buccal surface of the coronoid process undergoes
    resorption.
•   The area of the ramus below the sigmoid notch and
    superior portion of the condylar neck…deposition on
    lingual and resorption on buccal side.
•   Inferior edge of the mandible at the Corpus-Ramus
    junction……..resorption…….antegonial notch.
   Theclinical presence of a deep mandibular
    antegonial notch is indicative of a diminished
    mandibular growth potential and a vertically
    directed mandibular growth pattern.
    Singer CP,Mamandras AH,Hunter WS



   Gonial region is anatomically variable. The buccal
    side can be resorptive or depository depending
    on the direction of gonial flares.
• Mental foramen is near the lower border at
  birth.
• Adult: midway
• Elderly: near the upper border.
THE CONDYLE
•   Major site of growth with considerable clinical
    significance.
•   Endochondral growth occurs only at the articular
    contact part of the condyle.
•   Cartilage is non vascular, hydrophilic and
    pressure tolerant.
•   This mechanism develops as a response to local
    demands.
CONDYLE
   Lack of mandibular condyle and variable
    amounts of ramus…. Lack action of lateral
    pterygoid muscle on the same side.
   Deviation of mandible on oral opening.
   The condylar neck consists of intramembranous
    bone.
   The lingual and buccal sides of the neck have
    resorptive surfaces.
   What used to be the condyle becomes the neck
    by periosteal resorption and endosteal
    deposition..….. ‘V’ principle.
Where does the physical force that causes
primary displacement of the mandible come
                from….??
• Condylar remodeling acts with displacement as a
  co participant but not as the driving force in
  response to common activating signals.

• As the mandible is displaced away from its
  basicranial articular contact, the condyle and the
  ramus secondarily remodel towards it.
Growth by counterpart principle
RAMUS UPRIGHTING
• The ramus normally becomes vertically aligned
  during its development.




• A remodeling rotation of the ramus alignment
  occurs.
CLINICAL IMPLICATION
•   It must lengthen vertically
•   - to keep in pace with the growth of the
    pharynx and middle cranial fossa.
    - to accommodate the vertical
    nasomaxillary growth.
•   Gonial angle
•   The vertical growth continues even after
    horizontal has ceased to match the
    continued vertical growth of the
    midface.
• Condylar growth now becomes more vertically
  directed.
• The direction of resorption and deposition of the
  ramus reverses.
• Periosteal resorption on the labial bony cortex ,
  deposition on the alveolar surface of the labial
  cortex, resorption on the alveolar surface of the
  lingual cortex, deposition on the lingual side of
  the lingual cortex.
AGE CHANGES IN MAXILLA
AT BIRTH:
 The transverse and anteroposterior
  diameters are more than the vertical
  diameter.

 Frontal process is well marked            Inferior surface of maxilla at
                                            birth
 Body consists of a little more than the
  alveolar process

 The tooth sockets reaching to the floor of
  orbit
 Maxillary sinus is a mere furrow on the
  lateral wall of the nose.
                                            Anterior surface of maxilla at
                                            birth
IN ADULT:
 Vertical diameter is greatest
  due to the development of
  the alveolar process and
  increase in the size of the
  sinus.




IN THE OLD:
 The bone reverts to infantile
  condition.
 Its height is a result of
  absorption of the alveolar
  process.
AGE CHANGES IN MANDIBLE
In Infants & Children:
 The two halves of mandible fuse during the first year of life.

 At birth, the mental foramen,opens below the sockets for the
   two decidious molar teeth near the lower border.

   This is because the bone is made up of only the alveolar
    part with teeth sockets.
   The mandibular canal runs near the lower border.
   The foramen and canal gradually shift upwards.




                                Lower jaw of child and adult,
                                showing the mental foramen.
IN ADULTS
 The mental foramen opens midway between the
  upper and lower borders because the alveolar and
  subalveloar parts of the bone equally developed.
 The mandibular canal runs parallel with the
  mylohyoid line.
 The angle reduces to about 110 or 120 degrees
  because the ramus becomes almost vertical
IN OLD AGE
 Teeth fall out and alveolar border is absorbed, so
  that the height of the body is markedly reduced.
 The mental foramen and the mandibular canal are
  close to the alveolar bone.
 The angle again becomes obtuse about 140
  degrees because the ramus is oblique.
DISTURBANCES OF JAWS
1)   Agnathia
2)   Micrognathia
3)   Macrognathia
4)   Facial hemiatrophy
5)   Facial hemihypertrophy
DEVELOPMENTAL DISTURBANCES OF
LIP
1)   Congenital lip & commissural pits & fistulas
2)   Double lip
3)   Cleft lip
4)   Cheilitis glandularis
5)   Cheilitis grannulomatosa
6)   Peutz Jeghers syndrome
DEVELOPMENTAL DISTURBANCES OF
PALATE
1)  Cleft palate
During the 7th week, a shift in the blood supply of the
    face from the internal carotid to the external
    carotid artery occurs as a result of stapedial
    artery atrophy.
This is a critical time for mid face development
Deficient blood supply defects of upper lip and
    palate.
2) Median cleft face syndrome
Growth & development of maxilla and mandible
The depth of the mandibular antegonial notch as an
indicator of mandibular growth potential
Am J Orthod Dentofacial Orthop. 1987 Feb;91(2):117-24.
Singer CP, Mamandras AH, Hunter WS.
A dosage-dependent role for Spry2 in growth and
patterningduring palate development
        Ian C. Welsh, Aaron Hagge-Greenberg, Timothy P.
O’Brien*
   Mechanisms of Development 124 (2007) 746–761
THANK YOU
ADD
DERIVATIVES OF PHARYNGEAL
 ARCHES
ARCHES             NERVE             MUSCLES            SKELETAL         ARTERY
I Maxillary arch   Trigeminal        MOM                Mandible,        Maxilary
                                                        Maxilla,incus,
                                                        malleus

II Hyoid           Facial            Muscles of facial Stapes, styloid   Stapedial(embr
                                     expression        process,lesser    yonic)
                                                       cornu & upper     Corticotympani
                                                       part of body of   c(adult)
                                                       hyoid,


III                Glossopharyng     Stylopharyngeu     Gr. Cornu &      Common
                   eal               s                  lower part of    carotid
                                                        body of hyoid

IV & VI            Sup laryngeal &   Intrinsic          Thyroid,         IV- rt subclavian
                   recurrent         muscles of         cricoid,
                   laryngeal         larynx, pharynx,   arytenoid,       VI - pulmonary
                                     levetor palatini   corniculate,
                                                        cuneform
AGE CHANGES IN MANDIBLE
•   Mandible is relatively
    small at birth.
•   Eruption of teeth and
    development of
    alveolar process
    contribute to its vertical
    growth.
•   Assumes a more
    forward position.
•   With the loss of teeth,
    alveolar process
    resorbs reducing the
    mandibular height.

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Growth & development of maxilla and mandible

  • 1. GROWTH AND DEVELOPMENT PRE-NATAL & POST-NATAL GROWTH OF MAXILLA AND MANDIBLE
  • 2. CONTENTS 1)Pre Natal development of Maxilla  Embryonic development  Meckel’s cartilage  Development of palate  Mech’ of palate elevation  Palate remodelling 2)Post Natal development of Maxilla  Displacement  Remodelling  Growth at sutures  Growth in height,wifth & length  Key ridges  Maxillary sinus
  • 3. CONTENTS 1) Pre Natal development of Mandible 2) Post Natal development of Mandible  Growth timing  Sites of Growth  Development of ramus,lingual tuberosity,condyle  Growth by counterpart principle  Ramus uprighting  Age changes in Maxilla  Age changes in mandible  Developmental disturbances of face,lip,palate  REFERENCES
  • 5. ANATOMY OF THE MAXILLA PARTS OF MAXILLA. 1. BODY –large and pyramidal in shape. 2. FOUR PROCESSES. Frontal Zygomatic Alveolar Palatine Maxilla houses the largest sinus of the face, the maxillary sinus
  • 6. DEVELOPMENT OF MAXILLA Maxilla forms within the maxillary prominences extending ventrally from the dorsal aspect of a much larger mandibular swelling. Ossification of maxilla begins slightly later than in the mandible.
  • 7. DEVELOPMENT OF MAXILLA  The primary ossification centre appears for each maxilla in the 7th week.  The secondary centers are at- zygomatic, nasopalatine and orbitonasal areas  It lies in the angle formed by the infraorbital nerve and anterior superior alveolar nerve,above the part of the dental lamina from which the canine tooth germ develops.
  • 8. DEVELOPMENT OF MAXILLA  The premaxilla begins to ossify from two centres in the latter part of the 7th week.  Ossification spreads by: - Bony trough formed for infraorbital nerve - Palatine process  Maxillary sinus – 16th week
  • 9. Around the 4th week of intra-uterine life, the developing brain and the pericardium form two prominent bulges on the ventral aspect of the embryo. These bulges are separated by the primitive oral cavity or stomatodeum. The floor of stomodeum is formed by the buccopharyngeal membrane which separates it from the foregut. The pharyngeal arches are laid down on lateral and ventral aspects of the cranial most part of the foregut which lies in close approximation with the stomodeum
  • 10. Initially, there are 6 pharyngeal arches, but the 5th one usually disappears as soon as it is formed leaving only five.  They are seperated by 4 branchial grooves.  The first arch is called MANDIBULAR ARCH and second arch is called HYOID ARCH.
  • 11. MECKEL’S CARTILAGE It is derived from the first branchial arch around the 41st – 45th day of intra-uterine life  It extends from the cartilaginous otic capsule to the midline or symphysis and  provides a template for guiding the growth of the mandible.  A major portion of this cartilage disappears during growth and the remaining part develops into following
  • 12. DEVELOPMENT OF PALATE  Palatogenesis begins towards the end of 5th week and is completed by about 12th week.  The palate develops from two primordia.  Primary palate  Secondary palate
  • 13. PALATE Primary palate  At the end of 5th wk  Develops from deep part of inter maxillary segment of the maxilla.  Internal merging of medial nasal prominences.  Represents only a small part of adult hard palate.
  • 14. PALATE Secondary palate  Primordium of the hard and soft palate posterior to the incisive foramen.  Begins to develop in the 6th wk, from shelf like structures called lateral palatine processes.
  • 15. PALATE  The tongue is initially interposed between the secondary palatal shelves.  The palatal shelves become positioned above the tongue to allow for fusion in the midline.
  • 16. PALATE  The processes fuse in the midline and with the nasal septum and posterior part of primary palate.  begins anteriorly during the 9th wk and is completed posteriorly by the 12th wk.
  • 17. PALATE  The posterior part of palatal processes remains unossified, they extend posteriorly beyond the nasal septum and fuse to form soft palate and uvula.
  • 19. MECHANISM OF PALATE ELEVATION Elevation of the palate o Descent of tongue influenced by the growth of the Meckel’s cartilage and mandible. o Myoneural activity in the tongue. o Mouth opening reflexes
  • 20. MECHANISMS OF PALATE ELEVATION INTRINSIC  Hydration and polymerization of intracellular substances producing an elastic elevating force.  Differential growth of one side of the palatal shelf.  Triger produced by a build up mucopolysaccharides.  Serotonin release from neural tissue.
  • 21. PALATE Genesis of cleft palate o Delay in shelf elevation o Disturbance in mechanism of shelf elevation o Failure of shelves to contact due to lack of growth o Failure to displace the tongue during closure o [Pierre robin syndrome] o Failure to fuse after contact as epithelium does not break down o Rupture after fusion o Defective merging
  • 22. The formation of the palate involves the coordinated outgrowth, elevation and midline fusion of bilateral shelves leading to the separation of the oral and nasal cavities.  Reciprocal signaling between adjacent fields of epithelial and mesenchymal cells directs palatal shelf growth and morphogenesis.  Loss of function mutations in genes encoding FGF ligands and receptors have demonstrated a critical role for FGF signaling in mediating these epithelial–mesenchymal interactions.  Hence, deletion that removes the FGF signaling antagonist Spry2 have cleft palate
  • 23. PALATAL REMODELING  External side of the anterior part of the maxillary arch is resorptive… with bone being added onto the inside of the arch…..increase in arch width…..increase in palatal width… V principle.  Growth along mid palatal suture.  As palate descends inferiorly…. - It occupies a different position
  • 24. CLINICAL IMPLICATION  In RME, remodeling of maxilla follows clinically induced displacement.  lateral aspect of maxilla is resorptive.  After fusion of mid palatal suture, increase in arch width is due to remodeling of the alveolar process.
  • 25. INTER MAXILLARY SEGMENT  It is composed of - a labial component : philtrum of upper lip -upper jaw component : carries four incisor teeth. - palatal component : that forms the triangular primary palate. The intermaxillary segment is continuous with the rostral portion of the nasal septum which is formed by the frontal prominence.
  • 26. POST NATAL GROWTH OF MAXILLA
  • 27. DEVELOPMENT OF MAXILLA Growth occurs by:  Apposition of bone  Surface remodeling Movement downward & forwards:  Cranial base growth  Growth at sutures
  • 28. POST NATAL GROWTH OF MAXILLA:-  Growth of nasomaxillary complex is produced by following mechanism:-  Displacement (translation ie acc’ to moss) :-leads to apposition of bone at sutures  Surface remodeling(transposition) apposition resorption
  • 29. DISPLACEMENT  Primary displacement: the process of physical carry, takes place in conjunction with a bone’s own enlargement; joint contacts are important in this process.  Secondary displacement: the movement of bone and its soft tissues is not directly related to its own enlargement .It is a fundamental part of the overall process of craniofacial enlargement
  • 30. own enlargement not directly related
  • 31.  It is physical movement of bone.  Causing secondary deposition of bone at sutures  Downward and Forward growth
  • 32. REMODELLING  The functions of remodeling includes: a) To progressively create the changing size of each whole bone b) To sequentially relocate each of the component regions of the whole bone to allow for overall enlargement
  • 34. As maxilla grows due to primary displacement its anterior surface tends to resorb as part of remodeling.
  • 35. GROWTH AT SUTURE The maxilla is connected to the cranium and the cranial base by a number of sutures. These sutures include : Fronto- nasal suture. Fronto– maxillary suture. Zygomatico– maxillary suture. Pterygo– palatine suture. Zygomatico – temporal suture.
  • 36. POSTNATAL GROWTH OF MAXILLA  Growth in height - vertical  Growth in width - transverse  Growth in length - A -P
  • 37. TRANSVERSE DIMENSION (IN WIDTH)  Growth in midpalatine suture  remodelling at lateral surface of alveolar process
  • 38. A-P DIMENSION(IN LENGTH) Maxillary Palato primary secondary tuberosity -maxillary suture displacement
  • 39. VERTICAL DIMENSION (IN HEIGHT) Eruption of Primary Patatal teeth displacement remodelling
  • 40. SECONDARY DISPLACEMENT OF NMC  Expansion of Middle Cranial fossa has secondary displacement effect on anterior Cranial floor and thus on underlying NMC.  Growth occurs in all the 3 dimensions  A-P dimension(in length)  Transverse dimension (in width)  Transverse dimension (in width)
  • 41. SECONDARY DISPLACEMENT (TRANSVERSE DIMENSION)  Left and right temporal lobes move away from each other  Increase in transverse width of middle cranial fossa  Increase in width of maxilla by-  Growth in mid palatine suture  Remodeling at lateral aspect of alveolar process
  • 42. SECONDARY DISPLACEMENT (A-P DIMENSION) Ant. & Middle cranial fossa move away from each other NMC carried in forward direction Bone deposited in tuberosity area Increase in A-P dimension
  • 43. SECONDARY DISPLACEMENT (VERTICAL DIMENSION) Middle cranial base is in inclined plane Increase in dimension of Middle cranial base causes displacement of NMC in downward direction
  • 44. NASOMAXILLARY REMODELLING  As clinically and biologically all inside and outside parts,region and surface participate directly in growth  So key factors in NMC growth includes • Lacrimal suture • Maxillary Tuberosity • Vertical drift of teeth • Nasal airway • Palatal remodelling • Cheek bone & zygomatic arch • Orbital remodelling
  • 45. LACRIMAL SUTURE (KEY GROWTH MEDIATOR)  Diminutive flakes of bony islands surrounded by many sutures forms perilacrimal sutural system  Without it a developmental ‘gridlock’ will occur among differentially developing multiple bones
  • 46. It slides maxilla downward along its orbital contacts.This allows whole maxilla to get displaced inferiorly  The lacrimal bone itself undergoes a remodeling rotation ,because the more medial superior part remains with the lesser expanding nasal bridge,while the more lateral inferior part moves markedly outward to keep pace with the greater expansion of the ethmoidal sinuses.
  • 47. MAXILLARY TUBEROSITY  The horizontal lengthening of the bony maxillary arch is produced by remodeling at the maxillary tuberosity  Established by the posterior boundary of anterior cranial fossa  It is a depository field  the maxillary tuberosity is important in clinical orthodontics.it is also a major site of maxillary growth  It lengthens posteriorly
  • 48. MAXILLARY TUBEROSITY It lengthens posteriorly A-P Deposits on buccal surface width Deposits on alveolar ridge height
  • 49. KEY RIDGE  Reversal lines occur at Key Ridge  Anterior to it : Resorption  Posterior to it: Apposition * Reversal line: Irregular lines containing concavities directed away from the bundle bone and serving as histologic indications that resorption has taken place up to that line from the marrow side.
  • 50. THE NASAL AIRWAY  Lining surface of bony wall and floor  Resorptive  Lateral and anterior expansion of nasal chamber  Downward relocation of palate  The airway functions as a key stone for face  Its obstruction can cause variation in facial skeleton
  • 51. PALATAL REMODELING o Anteriorly - labial side is Resorptive oand palatal side is depository causes o widening of palate acc to V principle o As the palate grows inferiorly by the remodeling process, a nearly complete exchange of old for new hard and soft tissue occurs oGrowth at mid palatal suture plays a role in the progressive widening of the palate and alveolar arch
  • 52. MAXILLARY SINUS  All internal surfaces are resorptive except medial nasal wall  Rapid continous downward growth  Close proximity to buccal maxillary teeth
  • 53. EXPANSION OF MAXILLARY SINUS At birth - 7 mm length - 4 mm height - 4 mm width Expands at rate of - 2 mm vertically yearly - 3mm A-P yearly Expansion by - bone resorption - by tooth eruption (as vacated bone become pneumatized)
  • 54. THE CHEEK BONE & ZYGOMATIC ARCH  The growth changes of the malar complex are similar to those of maxilla itself  The malar region and the anterior part of the zygoma undergo posterior remodeling movements.  The inferior edge of the zygoma is heavily depository  As the malar region grows and becomes relocated posteriorly, the nasal region is enlarging in an opposite,anterior direction,drawing out the nose and making face deeper,anteroposteriorly
  • 55. ORBITAL GROWTH  Follows ‘V’ principle  Enlarging displacement occurs  Growth at sutures  orbital floor moves
  • 56. VARIATION IN NMC GROWTH  class II ( excessive mid face growth)  class III (decreased midface growth)  It’s common site for single most common craniofacial anamoly Cleft Palate
  • 58. PRE NATAL GROWTH OF MANDIBLE
  • 59. DEVELOPMENT OF MANDIBLE  2nd bone to ossify  Intramembranous + endochondrial  6th week of intrauterine life
  • 60. 36-38th day mandibular ectomesenchyme interacts with mandibular epithelium before primary ossification.  Intramembranous bone lies lateral to cartilage.  First ossification centre for each half arises in 6th week in region of bifurcation of IAN into mental, the ossification spreads dorsally and ventrally to form ramus and body.  Ossification stops at site where it would be lingula. Medially it meets its fellow counter part,distally upto middle ear.  Major cartilage disappears.
  • 61. Secondary accessory cartilages occur bet 10-14th weeks to form head of condyle, coronoid,mental protuberence  Coronoid cartilage: fuses with expanding intramembranous ramus before birth  Mental:1-2 small cartilages appear and ossify in 7th month iu in fibrous symphysial tissue  Condylar cartilage: appear 10th wk.  this is promordium for future condyle.  cartilage differentiate by interstitial n appositional growth.
  • 62. By 14th wk, 1st evidence of endochondral bone formtation  Condyle cart is an imp growth centre for ramus.  Condylar growth ia at its peak at puberty.  Occurs12-14 months post natally,2halves fuse into synostosis
  • 63. Mandible appears as single bone.  Basal bone forms one unit to with alveolar, condylar, coroniod, angular process and chin is attached.  They grow by functional matrix theory  Teeth act as functional matrix for development of alveolar bone  Temporalis influences coroniod process  Masseter n med pterygoid – at angle  Lateral pterygoid – at condyle
  • 64. POST NATAL GROWTH OF MANDIBLE
  • 65. POST NATAL GROWTH AND DEVELOPMENT GROWTH TIMING Growth of width of mandible is completed first, then growth in length and finally growth in height
  • 66. POST NATAL GROWTH AND DEVELOPMENT WIDTH OF MANDIBLE  Growth in width is completed before adolescent growth spurt  Intercanine width does increase after 12 years  Both molar and bicondylar width shows small increase until growth in length ends
  • 67. POST NATAL GROWTH AND DEVELOPMENT GROWTH IN LENGTH  Growth in length continues through puberty  Girls—14-15 years  boys---18-19 years
  • 68. MAIN SITES OF POST NATAL GROWTH IN THE MANDIBLE  Condylar cartilage  Posterior border of the Rami  Alveolar ridges
  • 69. CONDYLAR CARTILAGE  Secondary cartilage  Dual in function a) Articular b)Growth  Not a primary centre for growth ,but  Secondary in evolution  Secondary in embryonic origin  Secondary in adaptive responses to changing developments
  • 70. DEVELOPMENT OF MANDIBLE • Ramus • Lingual tuberosity • Condyle
  • 71. Ramus • It provides an attachment base for masticatory muscles. • It positions the lower arch in occlusion with the upper. • It is continuously adaptive to the multitude of changing craniofacial conditions.
  • 72. Moves progressively posterior by  Deposition Posterior part  Resorption Anterior part
  • 73. Superior part of ramus below sigmoid notch Lingual : deposition Buccal : Resorption  Lower part of ramus below the Coronoid process Buccal : depostion Lingual : Resorption
  • 75. • The mandible as a whole displaces anteriorly and inferiorly.
  • 76. • The former anterior part of the ramus becomes the corpus by resorptive and depository remodeling.
  • 77. THE LINGUAL TUBEROSITY  Major site of mandibular growth and remodeling.  Direct anatomic equivalent of the maxillary tuberosity.  Effective boundary between the basic structures- ramus and corpus.
  • 78.  Grows posteriorly by deposits on the on its posterior surface  Its prominence is augmented by the presence of a resorptive field below it, lingual fossa.  Simultaneuosly the part of the ramus behind the tuberosity remodels medially
  • 79. RAMUS TO CORPUS CONVERSION  The anterior border of the ramus resorbs relocating the ramus in a posterior direction.  Development takes place according to the ‘V’ principle.
  • 80. Coronoid process- its lingual surface faces posteriorly superiorly medially all at once. Deposits of bone on the lingual surface bring about growth superiorly, posteriorly and medially.
  • 81. The buccal surface of the coronoid process undergoes resorption. • The area of the ramus below the sigmoid notch and superior portion of the condylar neck…deposition on lingual and resorption on buccal side. • Inferior edge of the mandible at the Corpus-Ramus junction……..resorption…….antegonial notch.
  • 82. Theclinical presence of a deep mandibular antegonial notch is indicative of a diminished mandibular growth potential and a vertically directed mandibular growth pattern. Singer CP,Mamandras AH,Hunter WS  Gonial region is anatomically variable. The buccal side can be resorptive or depository depending on the direction of gonial flares.
  • 83. • Mental foramen is near the lower border at birth. • Adult: midway • Elderly: near the upper border.
  • 84. THE CONDYLE • Major site of growth with considerable clinical significance. • Endochondral growth occurs only at the articular contact part of the condyle. • Cartilage is non vascular, hydrophilic and pressure tolerant. • This mechanism develops as a response to local demands.
  • 85. CONDYLE  Lack of mandibular condyle and variable amounts of ramus…. Lack action of lateral pterygoid muscle on the same side.  Deviation of mandible on oral opening.  The condylar neck consists of intramembranous bone.  The lingual and buccal sides of the neck have resorptive surfaces.  What used to be the condyle becomes the neck by periosteal resorption and endosteal deposition..….. ‘V’ principle.
  • 86. Where does the physical force that causes primary displacement of the mandible come from….?? • Condylar remodeling acts with displacement as a co participant but not as the driving force in response to common activating signals. • As the mandible is displaced away from its basicranial articular contact, the condyle and the ramus secondarily remodel towards it.
  • 88. RAMUS UPRIGHTING • The ramus normally becomes vertically aligned during its development. • A remodeling rotation of the ramus alignment occurs.
  • 89. CLINICAL IMPLICATION • It must lengthen vertically • - to keep in pace with the growth of the pharynx and middle cranial fossa. - to accommodate the vertical nasomaxillary growth. • Gonial angle • The vertical growth continues even after horizontal has ceased to match the continued vertical growth of the midface.
  • 90. • Condylar growth now becomes more vertically directed. • The direction of resorption and deposition of the ramus reverses.
  • 91. • Periosteal resorption on the labial bony cortex , deposition on the alveolar surface of the labial cortex, resorption on the alveolar surface of the lingual cortex, deposition on the lingual side of the lingual cortex.
  • 92. AGE CHANGES IN MAXILLA AT BIRTH:  The transverse and anteroposterior diameters are more than the vertical diameter.  Frontal process is well marked Inferior surface of maxilla at birth  Body consists of a little more than the alveolar process  The tooth sockets reaching to the floor of orbit  Maxillary sinus is a mere furrow on the lateral wall of the nose. Anterior surface of maxilla at birth
  • 93. IN ADULT:  Vertical diameter is greatest due to the development of the alveolar process and increase in the size of the sinus. IN THE OLD:  The bone reverts to infantile condition.  Its height is a result of absorption of the alveolar process.
  • 94. AGE CHANGES IN MANDIBLE In Infants & Children:  The two halves of mandible fuse during the first year of life.  At birth, the mental foramen,opens below the sockets for the two decidious molar teeth near the lower border.  This is because the bone is made up of only the alveolar part with teeth sockets.  The mandibular canal runs near the lower border.  The foramen and canal gradually shift upwards. Lower jaw of child and adult, showing the mental foramen.
  • 95. IN ADULTS  The mental foramen opens midway between the upper and lower borders because the alveolar and subalveloar parts of the bone equally developed.  The mandibular canal runs parallel with the mylohyoid line.  The angle reduces to about 110 or 120 degrees because the ramus becomes almost vertical
  • 96. IN OLD AGE  Teeth fall out and alveolar border is absorbed, so that the height of the body is markedly reduced.  The mental foramen and the mandibular canal are close to the alveolar bone.  The angle again becomes obtuse about 140 degrees because the ramus is oblique.
  • 97. DISTURBANCES OF JAWS 1) Agnathia 2) Micrognathia 3) Macrognathia 4) Facial hemiatrophy 5) Facial hemihypertrophy
  • 98. DEVELOPMENTAL DISTURBANCES OF LIP 1) Congenital lip & commissural pits & fistulas 2) Double lip 3) Cleft lip 4) Cheilitis glandularis 5) Cheilitis grannulomatosa 6) Peutz Jeghers syndrome
  • 99. DEVELOPMENTAL DISTURBANCES OF PALATE 1) Cleft palate During the 7th week, a shift in the blood supply of the face from the internal carotid to the external carotid artery occurs as a result of stapedial artery atrophy. This is a critical time for mid face development Deficient blood supply defects of upper lip and palate. 2) Median cleft face syndrome
  • 101. The depth of the mandibular antegonial notch as an indicator of mandibular growth potential Am J Orthod Dentofacial Orthop. 1987 Feb;91(2):117-24. Singer CP, Mamandras AH, Hunter WS. A dosage-dependent role for Spry2 in growth and patterningduring palate development Ian C. Welsh, Aaron Hagge-Greenberg, Timothy P. O’Brien* Mechanisms of Development 124 (2007) 746–761
  • 103. ADD
  • 104. DERIVATIVES OF PHARYNGEAL ARCHES ARCHES NERVE MUSCLES SKELETAL ARTERY I Maxillary arch Trigeminal MOM Mandible, Maxilary Maxilla,incus, malleus II Hyoid Facial Muscles of facial Stapes, styloid Stapedial(embr expression process,lesser yonic) cornu & upper Corticotympani part of body of c(adult) hyoid, III Glossopharyng Stylopharyngeu Gr. Cornu & Common eal s lower part of carotid body of hyoid IV & VI Sup laryngeal & Intrinsic Thyroid, IV- rt subclavian recurrent muscles of cricoid, laryngeal larynx, pharynx, arytenoid, VI - pulmonary levetor palatini corniculate, cuneform
  • 105. AGE CHANGES IN MANDIBLE • Mandible is relatively small at birth. • Eruption of teeth and development of alveolar process contribute to its vertical growth. • Assumes a more forward position. • With the loss of teeth, alveolar process resorbs reducing the mandibular height.

Editor's Notes

  1. Each of these arches contain: A central cartilage rod that forms the skeleton of the arch. A muscular component called branchiomere. A vascular component. A neural element.
  2. The mental ossicles Incus and malleus Spine of sphenoid bone. Anterior ligament of malleus Spheno - mandibular ligament
  3. Nasal septum- tongue position – palatine shelf fusion the main part of the definitive palate is formed by two shelf like outgrowths from the maxillary prominences. The palatine shelves appear at the 6 th week of development and are directed obliquely at each side of the tongue. At the 7 th week, they attain a horizontal position and fuse to form the secondary palate. The shelves also fuse with the primary palate anteriorly.
  4. Accumulation of hyaluronic acid is the chief component of shelf elevating force. Degree of mesenchymal cell biosynthetic activity at different stages of palatal development .
  5. Micro gnathia Glossoptosis PIERRE ROBIN Upper airway obstruction Cleft palate
  6. Sprouty family of genes Sprouty homolog 2 Fibroblast growth factor A dosage-dependent role for Spry2 in growth and patterning during palate development Ian C. Welsh, Aaron Hagge-Greenberg, Timothy P. O’Brien*
  7. Natural increase in palatal width…… vertical drift of posterior teeth with lateral expansion (v principle).
  8. As a result of medial growth of the maxillary prominences, the medial nasal prominences merge both at the surface and at a deeper level- intermaxillary segment.
  9. Facial growth involves an interrelationship between all componenent parts ,hence no part is independent or selfcontained. Growth works towards an ongoing functional and structural equilibrium
  10. the lowest point of the zygomaticomaxillary ridge. Also called  zygomaxillare . Irregular lines containing concavities directed away from the bundle bone and serving as histologic indications that resorption has taken place up to that line from the marrow side
  11. 36-38 th day mandibular ectomesenchyme interacts with mandibular epi’ b4 prim ossification. Intramembranous bone lies lateral to cart. 1 ossification centre for each half arises in 6 th week in region of bifurcation of IAN into mental, the ossification spreads dorsally n ventrally to form ramus n body. Ossificatn stops at site whr it wud be lingula. Medially it meets its feloow counter part.distally upto middle ear. Major cart disaapears. Sphenomand lig
  12. Secondary accessory cartilages occur bet 10-14 th weeks to form head of condyle, coronoid,mental protrb Coronoid cart: fuses wit expanding intramemb ramus b4 birth Mentl:1-2 small cartilages appear n ossify in 7 th month iu in fibrous symphysial tissue Condylar cart: appear 10 th wk. this is promordium for future condyle.cart differentiate by interstitial n appositional growth. By 14 th wk, 1 st evidence of endochondral bone formtm Condyle cart imp growth centr for ramus. Condylr growth peak at puberty. 12-14 months post natally,2halves fuse into synostosis
  13. Mand appears as single bone. Basal bone frms one unit to wic alveolar, condylar, coroniod, angular pr n chin is attached. They grow by functoinal matrx theory Teeth act as functional matrix for developmnt of alv bone Temporalis influences coroniod pr Masseter n med pt –angle Lat pt- condylar
  14. Secondary in evolution Secondary in embryonic origin Secondary in adaptive responses to changing developments
  15. This allows for posterior lengthening of the body and the dental arch.
  16. The posterior development of the mandibular bony arch simultaneously proceeds into the region that was previously occupied by the ramus.
  17. Some of the key anatomic parts that participate in the relocation and remodeling process of the ramus and corpus cannot be seen or represented in 2d headfilms . Among these is the lingual tuberosity.
  18. It remodels mostly posteriorly with only a slight lateral shift. Becoz the bicondylar width does not increase as much as mandibular length beyond the early childhood period.
  19. Deposition occurs on the inner side of the v and resorption on the outer surface…..the direction of movement is towards the wide end of the v…
  20. The foramen from childhood maintains a constant position midway between the anterior and posterior borders of the ramus. The depth of the mandibular antegonial notch as an indicator of mandibular growth potential Am J Orthod Dentofacial Orthop.  1987 Feb;91(2):117-24. The depth of the mandibular antegonial notch as an indicator of mandibular growth potential. Singer CP ,  Mamandras AH ,  Hunter WS .
  21. GONIAL ANGLE : The angle formed by the junction of the posterior and lower borders of the human lower jaw
  22. The condyle was earlier believed to be responsible for the overall mandibular growth. Endo chon growth occurs here bcoz the pressure levels are beyond the capacity of the bone’s vascular soft tissue membrane.
  23. Lack of mand condyle does cause growth discrepancies but cannot be concluded that it is a growth centre. Although reconstruction of bone can be done to correct the deviation; the absent muscle function cannot be restored.
  24. Enlow’s growth prin’ : Growth of any facial or cranial part relates specificallyto other structural and geometric counterparts
  25. The gonial angle reduces to prevent change in occlusal relationship between maxillary and mandibular arches. At birth: 180 0 Adult: 90 0
  26. C.Gland: swelling and eversion of the lower lip C.Granu: sudden onset and progressive course terminating in chronic enlargement of the lips. [2]:799 Peutz: development of benign hamartomatous polyps in the gastrointestinal tract and hyperpigmented macules on the lips and oral mucosa
  27. Busulfan, Chlorambucil, Cyclophosphamide, Mercaptopurine, Methotrexate can cause clcp   fetus is most vulnerable to teratogens (substances that cause birth defects) between the 3rd and 8th week after fertilization, when the organs and systems are developing. Certain drugs and other teratogens, however, can harm the fetus at any point during pregnancy. Teratogenic drugs taken before the 20th day following conception often have an all-or-nothing effect, inducing miscarriage or having no effect at all. While drugs taken after the first trimester are less likely to result in serious birth defects, these teratogens can alter the function of organs and systems resulting in more subtle impairments and developmental defect (oshman & milisola ,LLP )