PRESENTED BY

Dr.Ranjeet k. chaudhary
PG 1 YR
 CONTENTS
 Introduction.
 Anatomy of maxilla.
 Articulations of maxilla.
 PRENATAL Growth of maxilla.
 POST NATAL growth of maxilla
 Growth rotations of the maxilla.
 Clinical implications.
 Summary.
 Bibliography.
INTRODUCTION
Being Orthodontists, our major role apart from restoring
aesthetics is to restore function and occlusion of teeth.
The growth and development of cranio-facial complex
marks the speed and outcome of orthodontic
treatment process. Hence, it is necessary to be well
versed with the concepts of growth.

Maxillae:
Latin: Cheek or jaw.

It is the second largest facial bone. Together with its

opposite twin, it embodies the whole upper jaw and
forms most of the floor and lateral walls of the nasal
cavity.
  ANATOMY OF MAXILLA

It consists of:
i.) Body.
ii.) Four Processes:
Frontal process.
Zygomatic process.
Horizontal Palatine Process.
Alveolar Process.
Maxilla – Medial View

Frontal process

Maxillary sinus

Maxillary process [palatine]

Horizontal plate of palatine
Palatine process[maxilla]

Alveolar process
Maxilla - Lateral View

Frontal process

Nasal notch

Zygomatic process
ANS
Alveolar process
ANATOMY OF MAXILLA 6
1. BODY: Hollow.
Roughly pyramidal.
Encloses the maxillary sinus.
4 Surfaces:
a.) Anterior. c.) Orbital.
b.) Infra-temporal. d.) Nasal.

Anterior Surface:
Parts:
Incisive fossa.
Canine fossa.
Infra-orbital foramen.
Nasal notch.
Infra-temporal Surface:
Concave .
Faces postero-laterally.
Forms anterior wall of infra-temporal fossa.
Separated from anterior surface by zygomatic
process.

It presents:
Foramina of alveolar canal.
Maxillary tuberosity.
Orbital Surface:
Smooth and triangular.
Forms the orbital floor.

Nasal Surface:
Forms greater part of lateral wall of nasal cavity.
It displays following structures:

Maxillary Hiatus.
Inferior meatus.
Greater Palatine Canal.
Naso-lacrimal Duct.
Oblique conchal crest.
PROCESSES OF MAXILLA:
Zygomatic Process:
Pyramidal projection where anterior, infra-
temporal and orbital surfaces converge.

Frontal Process:
Projects postero- superiorly between the nasal and
lacrimal bones.

Alveolar Process:
Thick and arched.
Provides socket to teeth roots.

Palatine Process:
Projects medially from lowest part of medial
maxillary aspect.
Maxilla – Medial View

Frontal process

Maxillary sinus

Maxillary process [palatine]

Horizontal plate of palatine
Palatine process[maxilla]

Alveolar process
Maxilla - Lateral View

Frontal process

Nasal notch

Zygomatic process
ANS
Alveolar process
ARTICULATIONS OF MAXILLA 6
Following bones articulate with maxilla:
i.) Cranial:
Frontal.
Ethmoid.
ii.) Facial:
Nasal.
Lacrimal.
Inferior nasal concha.
Vomer.
Zygomatic.
Palatine.
Opposite maxilla.
ARTICULATIONS OF MAXILLA 6
MAXILLARY SINUS
A large pyramidal cavity.

Walls: Orbital wall.

Alveolar wall.
Facial wall.
Infra-temporal wall.

Parts:
Apex: Lies laterally and is truncated.
Extends into zygomatic process.

Base: Lies medially.

Forms lateral wall of nasal cavity.
GROWTH OF THE
NASOMAXILLARY COMPLEX 3

The maxilla is a paired bone i.e. two maxilla join to form a

maxillae.

It is surrounded by and articulates with various bones that

influence its growth pattern.

Hence, growth of maxilla is studied as the growth of naso-

maxillary complex.
Anatomy Of Maxilla
1. nasal
2. frontal
3. ethmoid
4. sphenoid
5. maxilla
6. horizontal process of
palatine
7. superior concha
(ethmoid)
8. middle concha (ethmoid)
9. inferior concha
10. sphenopalatine foramen
11. medial pterygoid plate
12. pterygoid hamulus of
medial plate
 Anatomy Of Maxilla

At birth Adult
Pre natal growth and
development
Development of face
 Development of face : primarily between weeks 4 and 8.
 End of 8th week : face takes human appearance
 After 8th week : development - changes in facial
proportions and relative positions of facial components
 Prominences involved :
 Frontonasal -
 Maxillary
 Mandibular

Ectomesenchyme of Ist pharyngeal arch

 The pharyngeal arches
begin their development
during the fourth week as a
result of migration of
neural crest cells into the
head and neck region

 Neural crest cells migrating

from the rhombomeres
express homeobox genes
PRENATAL DEVELOPMENT:

Around the fourth week of intra-uterine life, a prominent

bulge appears on the ventral aspect of the embryo
corresponding to the developing brain.

This bulge is termed as Frontal prominence.

Below this bulge , a shallow depression corresponding to the
primitive mouth appears, called Stomodeum.

The stomodeum consists of:

i.) Oral groove.
ii.) Maxillary processes.
iii.) Mandibular arch.
FORMATION OF FRONTONASAL PROCESS 4
The floor of the stomodeum is formed by the
Buccopharyngeal membrane that separates it from the
foregut.

At about 27th day of intra-uterine life, this membrane

ruptures and the primitive oral cavity establishes a
connection with the foregut.

The mesoderm covering the developing brain proliferates

and forms a downward projection that overlaps the upper
part of the stomodeum. This downward projection is called
the Frontonasal Process.
4th week
 Stomodeum : At the end of 4
th week, the center of the
face is formed by stomodeum.

FRONTONASAL
MAXILLARY MAXILLARY

STOMODEUM

MANDIBULAR MANDIBULAR
Now, local thickenings develop within the ectoderm of the frontal
process. These thickenings are the Nasal Placodes.

These placodes eventually give rise to lining of the nasal pits, and
the olfactory epithelium.

During the fifth week , the olfactory placodes are bordered by

rapidly growing horse shoe shaped elevations. The medial aspects
of the elevations are the medial nasal processes and the lateral
limbs are the lateral nasal processes.

Thus after five weeks, the structures that border the upper aspect of
the oral cavity are:
i.) The frontal prominence in the midline.
ii.) The paired processes on either side of the frontal area.
iii.) Paired maxillary process at the upper lateral angles.

The maxilla, palate, upper lip and nose are derived from these
tissues.
DEVELOPMENT OF FACE 4
FORMATION OF PHILTRUM
The medionasal process grows downward more rapidly than
the lateral nasal processes and ultimately by the sixth week
to eighth week fuse on their lateral aspect with the
maxillary process and with the other medio-nasal process
at the same time.

The fusion gives rise to the central depression of the upper lip
called the Philtrum.
FORMATION OF PHILTRUM 4
I

Medial Nasal Process

Lateral nasal Process
Developing Maxilla
Odontogenic Epithelium

Developing Mandible
II Hyoid arch

Frontonasal Process

Developed Philtrum
5th week
 Nasal placodes
 bilateral localized ectodermal thickening
 Inferior and lateral part of frontonasal prominence.

 Medial and lateral nasal prominences

 horseshoe shaped ridges
 periphery of nasal placodes

 Nasal pit
 loss of ectoderm from the centre of nasal placode
 precursor of nasal cavity
 6th week
 Medial movement of
maxillary process
 Fusion of maxillary process
with medial nasal process
7th week
 Medial nasal process and maxillary process fuse to form the
upper lip
 Maxillary and mandibular process fuse laterally to form
commisure of mouth.
 Nasal process

Lateral Median nasal

nasal process
process
 At Seventh Week IUL-
1.Formation of upper lip
2.Intramembranous Bone
ossification Takes Place
3.Formation of Nasal Septum
4.Nasolacrimal Duct
5.Formation of Primary Palate
 At Seventh Week IUL
 Primary ossification center -for each maxilla at
termination of infraorbital nerve above canine
tooth dental lamina.

 Secondary center
zygomatic
orbitonasal
nasopalatine
intermaxillary
 Intermaxillary segment
 Medial growth of the maxillary
swellings : merging of the two
medial nasal swellings form the
intermaxillary segment.
 It is comprised of:
 A labial component : forms
the philtrum of upper lip.
 Upper jaw component :
Which carries 4 incisor teeth.
 Palatal component : Which
form the triangular primary
palate.
8th week
 Facial structure is well
recognisable.
 Eye closure commences
and they continue to
migrate medially
 Nasal pit also migrates
medially
 Rima oris reduces
significantly in size
laterally
 External ears are
developing
 Union of facial prominences
 This occurs by two developmental events at different locations.
 MERGING of the frontonasal,maxillary & mandibular
prominences.
Merging takes place as a result of migration into & or
proliferation of underlying mesenchyme into the groove.

 FUSION of the central maxillonasal components.

Takes place by disintegration of their contacting surface epithelia
, allowing inter - mingling of the under lying mesenchyme.
Merging and fusion
Development of tongue
PALATOGENESIS
 Growth of palate

 1st trimester-narrow
 2nd trimester-moderate width
 3rd trimester- wide
 Breadth>length
 Height changes less dramatic
 Development of palate
 The PALATE is the tissue that interposes between
the oral & nasal cavities”, it develops from 2 parts:
the primary palate & the secondary palate

Primary
palate

Structure
of palate
Secondary
palate
PALATOGENESIS
SIXTH AND
FIFTH NINTH TWELVETH
WEEK OF WEEK OF
IUL (CRITICAL IUL
PERIOD)
 PRE-NATAL GROWTH AND
DEVELOPMENT OF PALATE
 FORMATION OF PRIMARY AND SECONDARY
PALATE.

 ELEVATION OF PALATAL SHELVES.

 FUSION OF PALATAL SHELVES.

FORMATION OF PRIMARY PALATE
The deeper portions of these tissues form the dental tissues
i.e. dental arch, premaxillary area carrying the incisor teeth
and the palate. These structures which represent a single
unit are called Primary Palate.
Development of Palate

i.) Each maxillary process contributes a palatal shelf; and the

pre-maxilla region develops from the medial nasal process.

ii.) The lateral palatine shelves, which are vertically oriented

in the initial phases, fuse together and assume a more
horizontal position above the tongue around the seventh
week.

iii.) The palatal shelves which are covered by the epithelium,

fuse with each other and with the pre-maxillary portion of
the palate around eight and half weeks.
Formation
 Frontonasal process
of Primary palate
Medial nasal process

Intermaxillary process

Wedge shaped mass between internal surface of

maxillary prominence

Primary palate
(Pre-maxilla)
Formation of primary palate
During the deepening of the nasal sac & the
formation of the primary palate, the ectoderm at
the depth of the nasal sac proliferates to form a
thickened ectodermal plate, the nasal fin, which
then thins down to a thin double thickened
membrane called the “ oro-nasal membrane” ( 2
layers of ectoderm from stomodeum & nasal sac)

• The rupture of the oronasal membrane detaches

the primary palate from the nasal cavity
• primary palate & central parts of upper lip are one unit at
first, then by 8weeks of iul become separated by the
vestibular lamina
Formation of Secondary palate
Maxillary prominence

2 horizontal mesenchymal projections

Lateral palatine process

With each other
Fuse- Primary palate

Nasal septum
Secondary palate
Elevation of palatal shelves
The tongue is narrow & high filling all the oro-nasal
cavity, so the palatine shelves grow medially &
downwards (vertically) on either sides of the tongue
 At 8 weeks
Muscular Pressure Biomechanical
movement differences transformation

Vascular Elevation of palatal Increase in

changes shelves tissue turger

Intrinsic Differential Withdrawal

shelf force mitotic of embryo’s
growth face
Mechanism of transformation of palatal shelves from
vertical to horizontal
 Completed within a hours
 Earlier in males than females

1) Muscular movement :
- Withdrawal of embryo’s face from against the heart
prominence by uprighting of the head facilitates
jaw opening
- Pressure differences between the nasal and oral
regions due to tongue muscle contraction may
account for palatal shelves elevation
PS PS

T
2) Alteration in biomechanical and physical
consistency of palatal shelves (intrinsic shelve
force)
 ISF chiefly generated by accumulation and
Hydration of hyaluronic acid
 They are strongly hydrophilic and have the
capacity to withhold water
 The alignment of mesenchymal cells within the palate
shelves may force to direct the elevating force
3) Rapid differential mitotic activity
4) Alteration in vascular environment
 Vascularity controls the oxygen and nutritional elements in
face and palate
 There is a shift in the circulation in this region during the
critical time period of 7th to 8th week.
5) Sudden increase in the tissue turgour
 FUSION OF PALATAL SHELVES
Initially by epithelial
lining

Epithelial cells
degeneration

Mesenchyml
coalescence
Fusion of palatal shelves
 Twelfth Week

 Anteroposterior maxillo- mandibular

relationship approaches that of newborn infant

 Maxilla increases in height

 FORMATION OF PALATE
[SUMMARY]
Primordium of Formed by Derived from

Primary palate Pre maxilla Median palatine Frontonasal process

process

Secondary palate Hard and soft palate Lateral palatine Maxillary process
process
Ossification centers
 A Primary intramembranous ossification center appears for
each maxilla in the 7th week, at the termination of the
infraorbital nerve just above the canine tooth dental lamina.

 Secondary ossification centers

 zygomatic
 orbitonasal
 nasopalatine
 and intermaxillary appear and fuse rapidly with the primary
centers.
 Intramembranous Single ossification centers appear for each:
 first centers to appear, are those for the medial pterygoid plates
of the sphenoid bone
 palatine bones
 vomer
 zygomatic bones
 squamous portions of the temporal bones
 nasal and lacrimal bones
in the 8th week post conception
 The facial bones develop intramembranously from ossification
centers in the neural crest mesenchyme of the embryonic facial
prominences.

 The two inter-maxillary ossification centers generate the

alveolar ridge and primary palate.
 This area encloses the four maxillary incisor teeth; in the
neonate, it is demarcated by a lateral fissure from the incisive
foramen to the area between the lateral incisor and canine teeth
and forms the so-called os incisivum.
 Primary factors influencing the growth of the nasomaxillary
complex from the late embryonic period and throughout the fetal
period are expansion of brain and cranial vault and gowth of
anterior cranial base, including in particular anterior and inferior
growth of the nasal septum, as well as expansion of nasal cavity and
oronasal pharynx.
 Musculature of palate

 Tensor veli palatini 40 days 1st arch

 Palatopharangeous 45 days
 Levator veli palatini 8th week 2nd arch
 Palatoglossus 9th week
 Uvular muscle 11thweek 2nd arch
Growth in dimensions
height
width Arched
length palate

 Length - 7-8 weeks IUL

 Width - 4th month onwards
 Growth in dimensions
 Pre natal life (appositional growth in the alveolar margin)
length > width

 At birth (appositional growth in the maxillary tuberosity)

length = width

 Post natal life

width > length
Factors affecting growth of
palate
 Elevation of head and lower jaw
 Oxygen and nutritional deficiency
 Excess endocrine substances
 Drugs
 Irradiation teratoge
ns
 Vascularity
 PRESENTED BY
Dr.SIMRAN KOUR
PG 1 YR
 CONTENTS
 Introduction.
 Anatomy of maxilla.
 Articulations of maxilla.
 PRENATAL Growth of maxilla.
 POST NATAL growth of maxilla
 Growth rotations of the maxilla.
 Clinical implications.
 Summary.
 Bibliography.
 POSTNATAL
DEVELOPMENT OF
MAXILLA
POST NATAL GROWTH OF NASO-MAXILLARY COMPLEX
NMC comprises of bones and cartilages of nose and maxilla.
Histologically,
The nasomaxiilary complex, other than the nasal septum
grows by intramembranous bone formation. The nasal
septum grows by endochondral bone formation.
POST NATAL GROWTH OCCURS BY;
1. Primary growth
2. Secondary displacement
3. Surface remodelling
Growth sites:
i.Cranial base
ii) Sutures: 4 main sutures:
a.) Fronto-maxillary sutures.
b.) Zygomatico- maxillary sutures.
c.) Zygomatico- temporal sutures.
d.) Pterygo- palatine sutures.

iii.) Maxillary tuberosity.

iv.) Alveolar process.
v.) Nasal septum.
POSTNATAL GROWTH OF NASOMAXILLARY COMPLEX 2
MECHANISM OF GROWTH
i.) By secondary growth of maxilla due to growth in the
cranial base.

ii.) Sutural growth.

iii.) Growth of the cartilagenous nasal septum.

iv.) Appositional growth as well as modelling resorption on

the surfaces of bones.

v.) Role of functional matrices in the growth of nasomaxillary

complex.
ELONGATION OF THE ANTERIOR CRANIAL BASE IS ASSOCIATED WITH

THE CORRESPONDING
ENLARGEMENT OF THE
GROWTH IN NASO MAXILLARY
POSTERIOR COMPLEX
DIRECTION

THE COMPLEX
GROWS IN
POSTERIOR
DIRECTION AND IS
2 DISPLACED
ANTERIORLY
GROWTH OF SPHENO-OCCPITAL
SYNCHONDROSIS

CONSTITUTES THE GROWTH

EQUIVALENT FOR THE
NASOPHARYNX AND THE RAMUS OF
THE MANDIBLE

THE RAMUS GROWS IN A

POSTERIOR DIRECTION AND THE
ENTIRE MANDIBLE SHIFTS
FORWARD

THIS PROCESS COMPENSATES FOR

THE SAGITTAL RELATIONSHIP OF
THE MANDIBULAR ARCH TO THE
PROTRUDING NASOMAXILLARY
COMPLEX
 RAMUS

THE RAMUS GROWS

POSTERIORLY AND THIS PROCESS IS
UPWARD AND MOVES BASED ON NASAL
DOWNWARD WITH AND MAXILLO-
COMPENSATORY ALVEOLAR
CONDYLAR GROWTH GROWTH
(GRABER 1972)
BONE DISPLACEMENT DUE TO THE ENLARGEMENT
OF BONES AND SOFT TISSUES WHICH ARE NEARBY
OR NOT IMMEDIATELY ADJACENT IS TERMED AS
“SECONDARY DISPLACEMENT”

THIS process is not associated with the growth of the

bone itself. This type of displacement is initiated by
ENLARGEMENT OF ADJACENT OR REMOTE BONES
AND SOFT TISSUE
Its effect is transferred from BONE TO BONE AND
DEVELOPS IN RELATIVELY DISTANT AREAS
 SECONDARY DISPLACEMENT
OF THE MAXILLA

RESULTS FROM
ENLARGEMENT OF
THE MIDDLE CRANIAL
FOSSA

EXTENT OF DEGREE OF ANTERIOR

SECONDARY EXTENSION OF THE
DISPLACEMEN MIDDLE CRANIAL FOSSA
T
SECONDARY
DISPLACEMENT OF THE
NASOMAXILLARY
COMPLEX is caused by
growth of the MIDDLE
CRANIAL FOSSA and
the TEMPORAL LOBE
and is directed
FORWARD AND SECONDARY DISPLACEMENT =
DOWNWARD THE BONE IS CARRIED
AWAY WITHOUT BEING
REMODELLED
Weinmann and Sicher (1947)
Maxilla is related to cranium at least partially by the,
- Frontomaxillary suture
- Zygomaticotemporal suture
- Zygomaticotemporal suture
- Pterygogopalatine suture

These sutures are all oblique & more or les parallel with each
other. The growth in these areas would serve to move the
maxilla downward & forward.
Rate of Sutural Growth: 2
i.) Juvenile period:
Is an average of 1mm.

ii.)Prepubertal minimum :
Growth is 0.25 mm.

iii.) Pubertal maximum:

1.5mm/ year.

iv.) Cesation of growth:

At 17yrs. Of age.

The growth at sutures cease on

an average 2years before body
height.
Condylar growth was completed
a little later.
III. CARTILAGENOUS NASAL SEPTUM GROWTH
Nasal septum has innate growth potential and acts as a primary
growth site
It has a major role in growth of cartilagenous part of vomer and
perpendicular plate of ethmoid which contribute to the
downward and forward growth of maxilla
This growth also creates space in the posterior region at the
tuberosity area for the erruption of first permanent molars
CARTILAGENOUS NASAL SEPTUM GROWTH 2
IV. APPLICATION OF FUNCTIONAL MATRIX THEORY TO
THE GROWTH OF NASO-MAXILLARY COMPLEX.
According to Moss “ The head is a composite structure
operationally consisting of a number of relatively
independent functions.”

In the growth of the naso-maxillary complex, the oro-facial

capsule along with the oro-naso-pharyngeal functioning
spaces play an important role.
FUNCTIONAL MATRIX THEORY IN GROWTH OF
NASOMAXILLARY COMPLEX 2
As these spaces and other important orofacial matrices
expand, facial bones are passively carried outward
( downward, forward and laterally).

The resultant maxillary changes in the skeletal elements

would thus be secondary, compensatory and mechanically
obligatory.

Another important functional matrix in the orofacial region

is the teeth. As the teeth erupt, there is an increase in
height of the maxillary complex by the continued
apposition of the alveolar bone on the free borders of the
alveolar process.

The mid palatine suture is also an area which shows adjustive

or adaptive response to functional matrix stimulation.
 V. REMODELLING

The overall growth changes in the maxilla are the result of both a
downward and forward translation of the maxilla and a
simultaneous surface remodelling. The whole bony nasomaxillary
complex is moving downward and forward relative to the cranium,
being translated in space.
ENLOW’S ILLUSTRARATION SHOWING MAXILLARY
BONE REMODELLING 1
 Red fields = bone
deposition
 Blue field = bone
resorption
It is not necessary that the remodelling changes oppose the
direction of translation.
Depending on the specific location, translation and remodelling
may either oppose each other or produce an additive effect.

The effect is additive on the roof of mouth. This area is carried

downward and forward along with rest of the maxilla , but at the
same time, bone is removed on the nasal side and added to the
oral side thus creating an additional downward and forward
movement of the palate.

Immediately adjacent, however, the anterior part of the alveolar

process is a resorptive area so removal of bone from the surface
here tends to cancel some of the forward growth that otherwise
would occur because of translation of the entire maxilla.
 KEY FACTORS IN GROWTH OF
NASOMAXILLARY COMPLEX

• The Lacrimal Suture

• The Maxillary tuberosity
• Key ridge
• Vertical drift of teeth
• Nasal airway
• Palatal remodelling
• Downward maxillary displacement
• The Cheekbone and Zygomatic Arch
• Orbital Growth
 LACRIMAL SUTURE
(KEY GROWTH MEDIATOR)
 The lacrimal has remained,
phylogenetically, a separate bone.
 Despite its diminutive size, the
lacrimal represents the key pivotal
bone that maintains alignment
between the several differentially
growing and moving bones around
it.
 Provides slippage of multiple bones
along sutural interfaces
‘perilacrimal sutural system’ as
they all enlarge differentially.
 Rate and extent of movement
greatly exceed the growth of the
adjacent lacrimal bone

 The frontal process of the maxilla,

in effect, "slides" down its contact
with the slower growing lacrimal.
This differential manner of
movement is accomplished by
fibrous relinkage.

 A similar but somewhat less

marked adjustment process occurs
within the other sutural contacts
surrounding the lacrimal bone.
 As these bony walls in each of the
orbital cavities move laterally away
from each other, they also shift
distinctly upward and forward.
 The nearly perpendicular angle
between the medial orbital wall and
the floor in the very young skull
becomes opened considerably as
this area continues to expand.

 the breadth of the nasal bridge (C

and D) does not increase
proportionately but remains
relatively stable.
 The lateral expansion of
the orbital floor and
medial orbital wall
(ethmoidal portion) is
accommodated by
remodeling changes in the
lacrimal.
 The inferior portion of this
bone drifts laterally and
superiorly, and the upper
part moves medially
 MAXILLARY
 Helps in posterior and TUBEROSITY
horizontal lengthening of
arch
 Anterior displacement=
posterior lengthening
 lateral widening and
downward deposition :
Contributes to maxillary
sinus enlargement
 Diagram a :Bone growth proceeds along the
entire inner (lingual) side of the arch as well as
along its posterior margin (maxillary
tuberosity) and the posterior face of the
zygomatic process.
 Resorptive removal occurs from the outer
cortex of the premaxillary area and from the
anterior surface of the zygomatic process.
 Diagram b schematizes the apparent direction
of growth which results from the anterior
displacement of the maxillary body
accompanying its actual growth in a posterior
direction.
 Diagram c illustrates the mechanism of
posterior and lateral movement of the
combined zygomatic process of the maxilla and
the adjacent zygomatic bone
 Vertical crest belowKEY
the RIDGE
malar protuberence
‘muzzle’
 Reversal occurs at the key
ridge
 Posterior - apposition
 Anterior - resorption
 VERTICAL DRIFT OF TEETH
• Vertical drift –
significant intrinsic
growth factor
• provides
intramembranous bone
remodelling
• Moves the tooth in its
socket – usually called
extrusion
 Nasal airway
Lining surface of Resorptive
bony wall and floor
(except olfactory fossae)

Downward Lateral and

relocation of palate anterior
expansion
 Ethmoidal conchae
- lateral + inferior
deposition
- medial + superior
resorption

 Inter nasal septum

- lengthens vertically
at sutural junctions
 PALATAL REMODELLING
 The oral palate (and floor of the
nasal cavity) and the nasal spine
move in a downward direction by
bone deposition on the various
inferior surfaces together with
resorption from contralateral
superior surfaces (a).
 The premaxillary area
simultaneously moves downward
and somewhat posteriorly by an
equivalent process
 The entire V-shaped structure
thereby moves in a direction toward
the wide end of the V and
simultaneously increases in overall
size.
 Diagram a illustrates the
mode of downward
premaxillary growth. The
superior (buccal) surface is
resorptive (—), and the
inferior (lingual) surface is
depository ( + )

 Between stages 1 and 7, the

cortex moves downward and
becomes slightly extended in
an anterior direction because
of alveolar elongation.
 DOWNWARD MAXILLARY DISPLACEMENT

• Primary displacement of the ethmoidomaxillary complex

inferiorly
• New bone is added at all sutures and these sutures accompany
displacement produced by the soft tissues

• The balance of greater or lesser growth in posterior and anterior

maxilla is due to clockwise/counterclockwise rotatory
displacement caused by downward and forward growth of the
middle cranial fossa

• Nasomaxillary complex undergoes compensatory remodelling

rotation to sustain its position relative to the vertical reference
line and to the neutral orbital axis
Downward maxillary
displacement
 CHEEK AND ZYGOMATIC BONE
• Posterior side of malar protuberence within the
temporal fossa is depository
• Cheek bone relocates posteriorly as it enlarges
• Posterior relocation slows after dental arch length is
achieved during childhood
• Zygomatic arch moves laterally by resorption on the
medial side
• Zygoma and cheekbone complex are displaced
anteriorly and inferiorly in the same directions as the
maxilla
 Diagram showing the nature of
growth along the complex curvature
at the contact between the malar
area and the lateral wall of the nasal
region.

 This contour becomes expanded as

the nasal area (frontal process of the
maxilla and adjacent nasal bone)
moves in progressive superior,
lateral, and anterior directions
(black arrow). Simultaneously, the
malar area of the maxilla is receding
in a posterior direction (white
arrow).
(From Enlow, D. H., and S. Bang: Am.
J. Orthodont., 1965.)
 Age changesMAXILLARY SINUS
Expands -
2mm vertically
3mm A-P
every year

 Increase in size -
resorption in walls +
alveolus
 Maxillary sinus
 POST NATAL
 All internal surfaces
resorption
[expect medial]

 Rapid continuous
downward growth :
close proximity to
buccal maxillary teeth
 ORBITAL GROWTH
• Most of the lining roof and floor
are depository
• Lateral wall remodels by
deposition and medial by
resorpition
i)Forward remodelling of the nasal
and superior orbital rim,
ii) backward remodelling of the
inferior orbital rim and the
malar area
iii) downward remodelling of the
premaxillary region
• combine to produce rotation
and alignment of the midface
and upper facial regions
 GROWTH ROTATIONS OF THE MAXILLA 3
Bjork,1960s; carried out implant studies on the rotations of the jaws
during growth. Two types of rotations are:

a.) Internal Rotations. b.) External rotations.

After placing implants above the maxillary alveolar process, it was

observed that a core of the maxilla undergoes a small and variable
degree of rotation.
The internal rotation of the maxilla occurs and also occurs varying
degrees of resorption of bone on the nasal side and apposition of
bone on the palatal side, in the anterior and posterior parts of the
palate.
Variations also occur in the amount of eruptions of incisors and
molars.
These changes amount to external rotation.
For most of the patients, external rotation is opposite in direction
and equal in magnitude to the internal rotation, so that the two
rotations cancel and the net change in jaw orientation is zero.

SUMMARY:

Hence, maxillary growth is a process in which maxilla moves

uneventfully in a downward and forward direction.

It involves various methods of bone growth and has a series of

complex movements of many bones that comprise the maxillary
area.
Growth increments for maxilla:

1.) 0-5yrs. : 45% of total growth.

2.) 5-10yrs. : 65% completed.
3.) 10-20yrs.: Rest 35% completed.

The maxilla also grows in all the three dimensions, namely:

a.) Height.
b.) Depth.
c.) Width.

The maxilla completes its width quite early in life.

Also, greatest increase is seen in maxillary height followed by depth

and least in width.
COMPARATIVE GROWTH INCREMENTS IN HEIGHT, DEPTH
AND WIDTH IN MAXILLA 2
CLINICAL IMPLICATIONS
 CLINICAL IMPLICATIONS
1. Defects occuring during embryological or prenatal growth of
maxilla:

i.) Mandibulofacial dysostosis: Treacher Collin Syndrome.

A congenital syndrome. Both the maxilla and mandible are under-

developed due to generalized lack of mesenchymal tissue.
The problem arises due to excessive cell death in the trigeminal ganglion
that secondarily affects the neural crest derived cells.

ii.) Hemifacial microsomia ( Goldenhar Syndrome):

It is primarily a unilateral and always an asymmetric problem.

There is lack of tissue on the affected side. It is an abnormality in the
vascular supply of head.
There is early loss of neural crest cells.
Hemifacial Dysostosis 1 Hemifacial Microsomia 1
iii.) Craniofacial Dysostosis: 1
Crouzan’s Syndrome.

It is a genetic disease characterized by

a variety of cranial deformities.
This condition is characterized by
premature CRANIOSYNOSTOSIS.

Clinical features:

 Frontal prominence.
 Maxillary hypoplasia.
 Mandibular prognathism.
 High arched palate.
 Clefts (some cases).
 Parrot’s beak nose.
 Exophthalamus,
 Hypertelorism.
Clefts:
Clefts arise during the formation of organ systems, especially,
the pharyngeal arches and the primary and secondary
palates. They appear at locations where the fusion of various
facial processes fail to occur.

i.) Cleft Lip: The clefting of lip occurs due to failure of fusion
between the median and lateral nasal processes.
 UNILATERAL PARTIAL CLEFT LIP UNILATERAL COMPLETE CLEFT LIP

BILATRAL PARTIAL CLEFT LIP BILATERAL COMPLETE CLEFT

LIP
ii.) Cleft Palate:
It represents a disturbance in the normal fusion of the
palatine shelves: failure to unite due to lack of force,
interference by the tongue or a disparity in the size of the
parts involved .

8
iii.) Other Facial Clefts:

a.) Oblique facial cleft. b.) Lateral facial cleft.

 MALOCCLUSION DUE TO DISCREPANCIES IN MAXILLARY
GROWTH

a.) Maxillary Deficiency:

i.) Antero-posterior and vertical maxillary deficiency:

Both antero-posterior and vertical maxillary deficiency can contribute to

class III malocclusions.
If the maxilla is small or positioned posteriorly, the effect is direct.
If it does not grow, the maxilla rotates upwards and forwards producing an
appearance of mandibular prognathism,

Treatment: In children below 8yrs, this can be treated with Delaire type of
face mask that obtains anchorage from the forehead and chin.
HEAD GEAR AND CHIN CAP
ii.) Transverse maxillary constriction:
Skeletal maxillary constriction is distinguished by a narrow palatal
vault.
It can be corrected by opening the mid-palatal suture which
widens the roof of the mouth and floor of nose. The growth of this
suture helps in arch-widening and continues till late teens and
then ceases .

Treatment modalities:

a.) Rapid maxillary expansion or rapid palatal expansion:

Emerson C.Angell is considered the father of RME.
As sutural patency is vital to RME, it is essential to know when and
at what age synostosis occurs.

Persson(1973,1976) did histologic studies on timing and rate of

ossification.
Findings:

 Earliest closure -15yrs.

Oldest unossified suture- 27 yrs.

 Bony spicules appeared between 15-19yrs but these could be

removed by osteoclastic activity.

 Greater obliteration in posteriors than anteriors.

 5% of suture closed by 25yrs.

RAPID MAXILLARY EXPANSION 5
ii.) Slow expansion:5

Traditionally termed dento-alveolar expansion. The skeletal

changes can be observed.
b.) Maxillary excess:
Excess growth of maxilla in children leads to a skeletal class II
malocclusion which has a vertical as well as an antero-posterior
component i.e. too much downward and forward growth.

The treatment goal is to restrict the growth of maxillae while

allowing the mandible to grow to a more prominent and normal
relationship with it.

Treatment:
Application of extra-oral force via head gear.
Effect of Abnormal Habits
on
Nasomaxillary Growth 1

a.) Digital Sucking:

Maxillary arch fails to
develop in width in case of
prolonged thumb sucking
habit due to alteration in
the balance between cheek
and tongue pressures.
Respiratory pattern: 1
An altered respiratory pattern such as breathing through the mouth
rather than nose can change the posture of the head, jaw and
tongue. This , in turn, can alter the equilibrium of pressures on
the jaws and teeth; and affect both jaw growth and tooth position.

This leads to a condition called ADENOID FACIES.

SUMMARY
Maxilla is not a single bone entity. It is surrounded by and
articulates with various bones which play a significant role
in its growth. The naso-maxillary complex grows
predominantly by intra-membranous bone formation .
The growth of nasomaxillary complex is attributed mainly
to secondary displacement of maxilla, sutural growth,
growth of cartilagenous nasal septum, appositional growth
and remodelling; and finally the functional cranial
components.
Any disturbances during growth pre-natally or post-natally
may lead to descrepancies in growth of maxilla.
 REFERENCES
 Contemporary orthodontics - PROFFIT
 Orthodontics Current Principles and Techniques- GRABER
VANARSDALL (5th ed)
 The Human Face - ENLOW
 Handbook of orthodontics – MOYERS
 Textbook of orthodontics – SAMIR E. BISHARA
 Craniofacial development - GEOFFREY H. SPERBER
 Netter’s atlas of human embryology- LARRY R. COCHARD
 SPERBER G. H ,New Insight in Facial Development, Seminars in
Orthodontics, vol 12, 2006.
o Williams Peter L., Gray’s Anatomy, Churchill Livingstone
Publishers, 38 ed. ,1995, 599-602.

o Grant’s Atlas of Anatomy, ed.9, Williams and Wilkins,

Baltimore, 463.

o Shafer, Hine, Levy, Text Book of Oral Pathology, W.B,

Saunders, ed. 4 , 1993, 15-16.
 Enlow and Bang, growth and remodeling of human maxilla.
Am. J. Orthodontics, June, 1965.
 Orthodontic diagnosis – RAKOSI, GRABER, JONAS.
 Textbook of Craniofacial growth– SHRIDHAR PREMKUMAR