Concepts Of

Growth &
Development

Nayanika Priyam
I year Post Graduate
Contents • Introduction

• Components of Growth:
- Growth Mechanism
- Growth Pattern & Variability
- Growth Timing

• Mechanisms of growth:
- Growth processes
- Growth fields
- Growth movements

• Concepts and hypotheses of craniofacial

growth

• Conclusion
Introduction
Growth Growth is a general term implying that
something changes in magnitude

• Growth refers to increase in size” - Todd

• “Growth may be defined as the normal change

in the amount of living substance”- Moyers

• “Growth usually refers to an increase in size

and number” – Proffit

• “Change in any morphological parameter which

is measurable”- Moss

• “Self multiplication of living substance”-

J.S.Huxley
 – Development is a progress towards maturity” –

Development Todd

– “Development refers to all naturally occurring

progressive, unidirectional, sequential changes
in the life of an individual from it’s existence as
a single cell to it’s elaboration as a
multifunctional unit terminating in death” –
Moyers

– “Development connotes a maturational

process involving progressive differentiation at
the cellular and tissue levels” – Enlow
Major Themes of
Development • Changing complexity
• Shifts from competent to fixation
• Shifts from dependent to
independent
• Ubiquity of genetic control
modulated by environment
 Changing Complexity

• Takes place at all level of organization from the sub-cellular to the

whole organism

• Normally complexity increases with development.

• Most complex period of developing dentition is transition of

dentitions.
 Shifts from competent to fixation

• Undifferentiated cells once differentiated become fixed.

Shifts from dependent to independent

• Development brings greater independence at most levels of

organization.
 Ubiquity of genetic control modulated by
environment

• Genetic control of development is constantly being modified by

environmental interactions
 Growth and
• Growth is largely an anatomic
Development phenomenon and quantitative in nature.

• Development is a physiologic and

behavioral phenomenon and qualitative in
nature.

• The two processes rely on each other

and under the influence of the
morphogenetic pattern, “the three fold
process”- self multiplication,
differentiation and organization, time
being the fourth dimension.
Components of
Growth
 Craniofacial growth may be divided into:

• growth mechanism
• growth pattern
• growth timing
Growth Mechanism
 • At the cellular level, there are three possibilities
for growth:
Soft Tissues – Increase in the size of individual cells :
hypertrophy
– Increase in the number of cells : hyperplasia
– Secretion of extracellular material

• Hyperplasia is the main mechanism hypertrophy

occurring secondarily

• Secretion of extracellular material also

contributes to growth in soft tissues and
uncalcified cartilage
• But different for hard tissue growth as it does
not mineralize
 • Tissue growth generally connotes an
Bone increase in size.

Growth
• Bone cannot enlarge by proliferation and/or
hypertrophy of existing cells or intercellular
material because of its calcified, rigid
nature.

• Therefore, the calcification process compels

bone to grow by specifically adapted growth
mechanisms which do not involve interstitial
expansion:
-Intramembranous
-Endochondral
 Undifferentiated cells in a connective tissue
Intra- membrane form a cluster
membranous
Bone Formation Primary center of ossification – small spicules of
bone are formed (Site of initial
ossification)

Osteoblasts form organic matrix - subsequently

ossifies

Meshwork of delicate bony trabeculae

Formation of osteoid which rapidly calcifies

 Endochondral Hypertrophy of chondrocytes and matrix
calcifies
Bone Formation
Cells degenerate

Invasion of blood vessels and connective

tissue cells.

Osteoblasts differentiate and produce

osteoid tissue.

Osteogenic tissues replace degenerating

cartilage.

Osteoblastic tissue calcifies.

• Primary cartilage- local factors do not influence as there is a
cartilagenous matrix
Ex: spheno-occipital synchondrosis, nasal septal cartilage

• Secondary cartilage- local factors do influence and modulate

growth
Ex: Condylar and Coronoid cartilage
 Growth Deposition: Addition of new
Processes bone

Resorption: Removal of bone

• The surface facing toward the

direction of progressive growth
receives new bone deposition (+).
The surface facing away
undergoes resorption(-)

Direction Of Growth
Growth Fields
• Outer and inner surfaces of a bone
blanketed by a mosaic-like pattern of
"growth fields“
• Either depository or resorptive activity:

If a periosteal growth field is resorptive,

the opposing endosteal field is depository
and vice versa
• These combinations produce the drift of all
parts of an entire bone.
• The irregularity is a response to the varied functions imposed
on the bone by various attachments.

• The operation of the growth fields is carried out by

membranes surrounding the hard tissue.

• The various depository and resorptive fields do not have the

same rate of activity.

• The growth movement of the bone follows the pace setting

movement of the overall growth field.
• It is important to understand the plan of distribution of the
major growth fields as these patterns can show us if we are
working with or against growth.

• Ex. Distalization of maxillary molars putting them into a

depository field or labial placement of lower anteriors into a
resorptive field.

• Variations in the facial structure can be due to a change in-

-Pattern of the fields.
-Placement of the boundaries.
-Rates and amounts of deposition and resorption.
-Timing of growth activity among different fields.
 Growth Site Growth Center
• Growth fields having special • According to Baume growth
role in the growth of the center can be described as
particular bone are called ‘Places of endochondral
growth sites ossification with tissue
• Areas of periosteal/ sutural separation force’
bone formation • Force, energy or motor for
- mandibular condyle bone growth (tissue
- maxillary tuberosity separating capacity) resides
- synchondroses of the primarily within its growth
basicranium center
- sutures • Areas of primary
- the alveolar process cartilaginous/ endochondral
ossification
• A growth site is merely a location where growth occurs
• Center is a location where independent growth occurs
• All centers of growth are also sites, but the reverse is not true
 The basic phenomena involved in the growth mechanisms:

• Conversion of cartilage
- synchondroses
- nasal septal cartilage
- condylar cartilage
• Sutural deposition
• Periosteal remodeling
Synchondroses
• Temporary bands of cartilage at the
junction of bones of endochondral origin

• Regarded as growth center & pacemaker of

cranial base
• Only a few persist postnatally in the midline
of basicranium
Spheno-occipital synchondrosis
Inter-sphenoidal synchondrosis
Spheno-ethmoidal synchondrosis
Nasal Septal
Cartilage • Plays an important role in the prenatal
and very early postnatal growth of the
middle face

• According to Scott, the septal cartilage

occupies a unique location for pushing the
whole maxilla forward and downward

• But functional matrix by Moss, suggests

that the nasal septal cartilage is a locus of
secondary, compensatory, and mechanical
growth for a prior passive displacement of
the midfacial bones
Condylar Secondary cartilage- participates in growth
Cartilage early in human life and absorbs pressure
forces later in life

• The condyle and its cartilage participate

in regional adaptive growth; the condyle
has a great capacity to adapt to
mandibular displacement during growth

• Thus not a major growth center for the

whole mandible
Sutures • Displacement growth is made possible by
the cranio­facial sutures

• Ossifies when cranial growth ceases

• The main biologic function of the sutural

tissue:
– To unite bones -allows minor movement
– To act as areas of growth
– To absorb mechanical stress -protecting
the osteogenic tissues of the bone
There are two schools of thought regarding the growth at sutures:

• Sutures are 3 layered structures having two bones separated by a single layer of
connective tissue. The connective tissue layer acts as the proliferating zone. Implies
tissue separating forces in the sutural tissue.

• Sutures are 5 layered with the 2 bones on either side having 2 layers of periosteum with
a 5th intervening connective tissue layer.

The role of this fifth layer is seen in allowing for slight adjustments
between the bones during growth, while the active proliferating role is played
by the cambial layers of the periosteums of each bone.
Periosteum • Considered an osteogenic zone

• The influence of the periosteum is of

greatest significance for the change in size
and shape of the bones

• Matrix-producing and proliferating cells are

subject to mechanical influence;

If the pressure exceeds a certain threshold

level, osteogenesis ceases and osteoclasts
appear leading to resorption but if exposed
to tension, it responds with bone deposition
Growth • Growth pattern refers to the change in the
size and shape of the bone.
Pattern • Bone grows by two fundamental
physiologic processes:
- Modeling
- Remodeling
 Modeling
• According to Roberts et al-modeling
and remodeling are 2 distinct
phenomena.
• In bone modeling independent sites
of resorption and formation change
the form (shape, size or both) of a
bone.
• Bone remodeling is a specific,
coupled sequence of resorption and
formation occurring to replace
previously existing bone.
• Bone modeling is the dominant process of facial growth and
adaptation to applied loads such as headgears, rapid palatal
expansion, and functional appliances.

• Modeling changes can be seen on cephalometric tracings.

• Remodeling changes are apparent only at microscopic level.

• The mechanism for internal remodeling of dense compact bone is

through axially oriented cutting and filling cones.
 • It is a differential growth activity
Remodeling involving deposition at one end and
resorption at the other

• Basic part of the growth process.

• A bone remodels during growth because

its regional parts move ("drift“) from one
location to another as the whole bone
enlarges.
Relocation • Progressive and sequential movement of
component parts as a bone enlarges
• Relocation is the basis for remodeling.
The mandibular ramus moves progressively
posteriorly by remodeling; Resorption in the
anterior border and deposition in the
posterior border
The whole ramus is thus relocated
posteriorly, and the posterior part of the
lengthening corpus becomes relocated into
the area previously occupied by the ramus
 In the maxilla, the palate grows downward by periosteal resorption on
the nasal side and periosteal deposition on the oral side.
 Types of 1.Biochemical remodeling: molecular level-
Remodeling: maintains calcium levels
2.Secondary remodeling: by Haversian
systems and rebuilding of cancellous
bone
3.Pathologic remodeling: occurs after
disease or trauma
4.Growth remodeling
Functions of 1. Sequentially relocate each
component of the whole bone
Remodeling
2. Progressively change the shape of
the bone to accommodate its
various functions
3. Progressively change the size of
whole bone
4. Progressive fine tune fitting of all
the separate bones to each other
and to their contiguous growing,
functioning soft tissues .
5. Carry out continuous structural
adjustments to adapt to the intrinsic
and extrinsic changes in conditions.
Enlow’s V-
principle • One of the basic concepts in facial
growth

• Many facial and cranial bones, or parts

of bones, have a V-shaped configuration

• Bone deposition occurs on the inner

surface of the "V“ and resorption takes
place on the outer surface

• The direction of movement is toward

the wide end of the "V"
 Example with V oriented
vertically and horizontally
• When bone is deposited on lingual side of coronoid process,
growth proceeds and this part of the ramus increases in vertical
dimension.
• These deposits also produce a posterior direction of growth
movement of the coronoid processes
• V principle applied to the mandible causes increase in both
posterior and superior directions
• Causes an increase in the transverse dimension of the maxilla-
Increases the airway space.
 Growth Movements
Two kinds of growth movements are seen during the enlargement of
craniofacial bones:

• Cortical drift
• Displacement
 Cortical Drift

• Drift includes both relocation and shifting of an enlarging portion of

the bone by the remodeling action of its osteogenic tissues.
• The continuous remodeling maintains the shape and proportions of
the bone throughout the growth period. As bone deposition occurs
during a simultaneous breakdown of opposing bone surfaces, the
bone will migrate in relation to a fixed structure. This migration
through remodeling is known as drift.
 As a general rule, the surface towards which growth occurs is
appositional, whereas the surface facing away from the direction of
growth is resorptive

The two processes do not always occur with the same intensity.
Rather, appositional activity normally exceeds resorption during the
growth period
Due to new bone deposition on one surface, all other parts of the
structure will undergo shifts in relative position, a movement that is
termed relocation . As a result of this process, further adaptive
bone remodeling has to take place, to adjust shape and size of the
bone to its new position.
An example of such passive drift in the facial region is the hard
palate, which subsides in relation to the overlying structures, due to
resorption of the nasal floor and concomitant deposition on the roof
of the palate. Relocation and structural remodeling thus are closely
related to each other.
 Displacement
• Displacement is a physical movement of the whole bone as a single unit
• Articulations are areas ‘away’ from which the displacement movements
occur as the bone enlarges.
• Amount of enlargement equals extent of displacement.

Two types of displacements:

- Primary
- Secondary
 Primary Displacement

• As a bone grows by surface deposition, it is simultaneously carried

away from other bones in direct contact with it.
• This creates the "space" within which bony enlargement takes
place
• The new bone deposition does not cause displacement by pushing
against the articular contact surface of another bone; the bone is
carried away by the expansive force of the growing soft tissues
surrounding
 Secondary Displacement

• Secondary displacement is the movement of a whole bone caused by the

separate enlargement of other bones, which may be nearby or quite
distant

• The secondary displacement is not associated with growth of the bone

itself but initiated by enlargement of adjacent bones and soft structures
and transferred to adjacent bones.
• For example, increase in size of the bones of middle cranial
fossa results in a marked displacement of the whole maxillary
complex anteriorly and inferiorly

• This is independent of the growth and enlargement of the

maxilla itself
 In summary, the overall skeletal growth process (displacement and
remodeling) carries out two general functions:

• It positions each bone

• It designs and constructs each bone and all of its regional parts to
carry out that bone's multifunctional role.
 “Domino
effect”
growth changes
can be passed on
from region to
region having
effect at a distant
site.
Growth Pattern
and
Variability
Pattern • Pattern represents proportionality-
not just proportional relationships at
a point in time but change in these
relationships over time.

• Can be defined as-a set of

constraints operating to preserve the
integration of parts under varying
conditions or through time.
Cephalocaudal Gradient of Growth
• The accomplishment of normal human proportions is not
merely due to a general slowing down. Different tissues
grow at different rates at different times.

• The overall pattern of growth is a reflection of the growth of

the various tissues making up the organism.
 Differential Growth

• Scammon’s curves for growth

• A graph for four major tissues of the body

-lymphoid
-neural
-general
-genital
Predictability • Predictability of growth pattern is a
specific kind of proportionality that
exists at a particular time and
progresses towards another, at the
next time frame with slight variations

• Any change in growth pattern would

indicate some alterations in the
expected changes in body
proportions.
Variability • No two individuals with the exception
of monozygotic twins are alike.

• Clinically important to identify if an

individual is at the extreme of normal
variation or is outside the range.

• What is normal?
Normality • Normality refers to that which is usually
expected, is ordinarily seen or typical –
Moyers

• Normality may not necessarily be ideal so

rather than categorizing as normal or
abnormal, deviations from the normal
pattern is considered
 Age • Because of variability all individual at
a given chronological age are neither
Equivalence of the same size or same stage of
maturation

• It is better to compare biologic

development
• “Developmental ages” - skeletal age
and dental age are used
Timing
 Growth Timing

• One of the factors for variability in growth

• Timing variations arise because biologic clock of different

individuals is set differently

• Timing is largely genetically controlled

-sex related differences

-physical differences
-environmental
 Growth spurts
• Periods of sudden acceleration of growth

• Due to physiological alteration in hormonal secretion

• Timing-sex linked

Normal spurts are

• Infantile spurt – at 3 years age

• Juvenile spurt – 7-8 years (females); 8-10 years (males)

• Pubertal spurt – 10-11 years(females); 15-18 years (males)

 Changing Concepts and Hypothesis
of Craniofacial Growth

• Remodeling theory
• Genetic theory
• Sutural dominance hypothesis
• Scott’s hypothesis
• Functional matrix hypothesis
• FMH revisited
• van Limborgh’s concept
• Servosystem hypothesis
• Growth Relativity hypothesis
 Bone Remodeling Theory

• Brash (1930)

According to the theory:

• Bone grows only by apposition at the surface.

• Growth of jaws takes place by deposition of bone at the posterior

surfaces of the maxilla and mandible.

• This is described as Hunterian growth.

Brash JC- The growth of the jaws and palate. In: The growth of jaws, normal and abnormal,
in health and disease. London: The Dental Board of the United Kingdom, 1924a:23-66.
• Increase in the size of the cranial vault occurs by periosteal
deposition of bone on the ectocranial surface and resorption on
endocranial surface

• Growth of the jaws takes place principally via deposition of

bone on the posterior surface of the maxillary complex and
mandibular ramus.

• Sutures and cartilages play no role in the growth of the

craniofacial complex.
 Schematic representation of the remodeling theory of craniofacial
growth using the cranial vault as a model.

Theories of Craniofacial Growth in the Postgenomic Era- DS Carlson; Semin Orthod

Vol 11:172–183, December 2005
 The Genetic Theory

• Brodie (1941)

• The genotype supplies all the information required for

phenotypic expression - genes determine and control the
process of craniofacial growth

• But the mechanism of action by the genetic unit and the

mechanism by which the traits are transmitted were not
understood until recently
 The Sutural Hypothesis

• Harry Sicher and Joseph Weinmann (1947)

• According to this theory, sutures, cartilages and periosteum are

responsible for facial growth and were assumed to be under
intrinsic genetic control.

• “The primary event in sutural growth is the proliferation of the

connective tissue between the two bones. If the sutural
connective tissue proliferates, it creates the space for
appositional growth at the borders of the two bones”.
• Sicher and Weinmann explained that growth of nasomaxillary
complex in a downward and forward direction is due to growth at
sutures which attach the complex to cranium which are parallel and
oblique

Sutures:
– Frontomaxillary
– Zygomaticomaxillary
– Zygomaticotemporal
– Pterygopalatine
 Cartilaginous Dominance Theory

• Proposed by James Scott in 1950

• According to the theory:
Intrinsic growth controlling factors are present in
– Cartilage
– Periosteum
Sutures are only secondary and dependent on extrasutural
influence
• Cartilaginous parts of skull responsible for cranial growth
• Nasal septum a major contributor in maxillary growth
• Condyle determines growth of the mandible

Cranium Cranial base

Synchondroses Pacemakers/
Growth Centers
Nasomaxillary Nasal septum

Complex Mandible Condyle

 Hunter & Enlow’s Growth Equivalence

• Important principle covering the development of the facial skeleton.

• As the individual components of the skull develop in different

directions, they must interact directly in order to compensate for the
various growth activities

• This is achieved by growth equivalents which act in opposing

directions
 Functional Matrix Hypothesis
• Melvin Moss based on original concept by Van der Klaaus
(1969)

• “The functional matrix is primary and the presence, size,

shape, spatial position and growth of any skeletal unit is
secondary, compensatory, and mechanically obligated to
changes in the size, shape, spatial position of its related
functional matrix” (Moss, 1968)
• Two types of functional matrices:
- Periosteal Matrix
- Capsular Matrix
 Periosteal Matrix

• Matrix related tissues that influence the bone directly through

the periosteum
– Muscles
– Blood vessels and nerves lying in grooves or entering or exiting
through foramina

• Affects a microskeletal unit- sphere of influence is usually

limited to a part of one bone
– Temporalis - coronoid process
– Tooth - alveolar bone
 Capsular Matrix

• Includes masses and spaces that are surrounded by capsules

– Neural mass with scalp and dura
– Orbital mass with supporting tissues of the eyes

• Affects macroskeletal units-several bones are simultaneously

affected
– Inner surface of calvarium
Theories of Craniofacial Growth in the Postgenomic Era- DS Carlson; Semin Orthod
Vol 11:172–183, December 2005
 Neurotrophism

• Neurotrophism is a non impulsive, transmitive neurofunction

involving axoplasmic transport providing for long term interaction
between neurons and innervated tissue, which homeostatically
regulates the morphological compositional and functional
integrity of those tissues

• Types of neurotrophism: Neuromuscular

Neuroepithelial
Neurovisceral
 The Functional Matrix Theory-Revisited
Concept of Mechanotransduction

• Mechanotransduction signifies cellular signal transduction

• Process by which macromolecular extrinsic stimuli are converted into

cellular signals, which can be internalized by a cell and processed so
that a suitable adaptive response can be generated.

The functional matrix hypothesis Revisited-The role of mechanotransduction by

ML Moss in AJO-DO -Volume 112, No. 1; July 1997
 Altered external environment

Vital cells are perturbed

Mechanoreceptors transmits an extracellular

physical stimulus into a receptor cell

Mechanotransduction – transduces or transforms the

stimulus into an intracellular signal

Intracellular activation of
oseteocytes and osteoblasts
 van Limborgh’s Compromise

• van Limborgh (1970)

• According to van Limborgh, craniofacial morphogenesis is

controlled by five different factors:

- Intrinsic genetic factors

- local epigenetic factors
- general epigenetic factors
- local environmental factors
- general environmental factors
• Intrinsic genetic factors
- Genetic factors inherent to the tissues
- exerts influence within the cells in which contained
- determine the characteristics of cells and tissues

Local
• Epigenetic factors
General

- Genetically determined factors effective outside the cells and tissues

in which produced
 Local- originating from adjacent structures ; embryonic induction
influences

General- originating form distant structures; sex and growth hormones

Local
• Environmental factors
General

- Non-genetically determined factors

Local- muscle forces

General- nutrition, oxygen supply
• Chondrocranial growth is controlled by intrinsic genetic factors

• Desmocranial growth is controlled mainly by local epigenetic factors,

also by local environmental factors

• General epigenetic and general environmental factors have very little

role to play.
 Servo-System/Cybernetics theory
• Alexandre Petrovic (1972)

• Growth of various craniofacial regions is the result of interaction of a

series of causal changes and feedback mechanisms

• According to the theory:

- control of primary cartilages takes a cybernetic form of
“command”
- control of secondary cartilages like condyle is comprised of both
direct effect of cell multiplication and also indirect effects.
• The physiologic effect of factors controlling the facial growth is not
limited to simple commands but includes relays, implying interactions
and feedback loops (Servosystem) as follows:

• Position of occlusal adjustment - peripheral 'comparator'

• Sagittal position of the upper dental arch- 'constant changing

reference input’ controlled by somatotrophin and somatomedin and by
growth of septal cartilage and tongue
• Sagittal position of the lower dental arch- controlled variable
• Signals originating from the 'peripheral comparator' of the
servosystem produce an increased postural activity of the lateral
pterygoid muscle enabling the lower dental arch to adjust to the
optimal occlusal position
• This increased muscle activity induces a posterior growth
rotation of the mandible and supplementary growth of the
condyle
 Growth Relativity Hypothesis
• John C Voudouris and Kuftinec Mladen (2000)

• States that –
“with orthopaedically displaced condyle, the bone
architecture is influenced by the neuromusculature & the
contiguous, non–muscular, viscoelastic tissues anchored
to the glenoid fossa & the altered dynamics of the fluids
enveloping bone”

• Foundations for Growth Relativity theory:

-Displacement
-Viscoelasticity
-Referred force (transduction)
 Mandibular advancement(displacement)
Synovial fluid dynamics
Influx of nutrients
Engorged blood vessels

Stretch of non – muscular viscoelastic tissues

Transduction

New bone formation

Improved clinical use of Twin-block and Herbst as a result of viscoelastic tissue forces on
the condyle and fossa in treatment and long–term retention: Growth relativity
by John C Voudouris and Kuftinec Mladen in AJO-DO 2000 Mar;117:247-66
 Conclusion
• Malocclusion and craniofacial deformity arise through variations in
the normal developmental process

• Planned changes of bone growth and morphology are a

fundamental basis of orthodontic treatment

• Thus knowledge of the basic concepts of craniofacial growth is

essential for sound treatment planning and desired outcome
 References
• Enlow D.H: Essentials of facial growth- 3rd Edition
• Gianelly A & Goldman H: Biologic basis of orthodontics-2nd Edition,
1971
• Proffit W.R: Contemporary orthodontics-3rd Edition, 2000

• Moyers R.E: Handbook of orthodontics- 4th Edition

• Koski K. Cranial growth centers: Facts or fallacies? ; AJO 1968 Vol 54:
566-583
• Sridhar Premkumar: Textbook of Craniofacial Growth
• T Rakosi, I Jonas, TM Graber: Orthodontic Diagnosis

• DS Carlson: Theories of Craniofacial Growth in the Postgenomic Era;

Semin Orthod Vol 11:172–183,Dec 2005

• ML Moss and L Salentijn: The functional matrix hypothesis Revisited- The

role of mechanotransduction in AJO-DO-Volume 112, No. 1; July 1997

• Brash JC- The growth of the jaws and palate. In: The growth of jaws,
normal and abnormal, in health and disease. London: The Dental Board of
the United Kingdom, 1924a:23-66
• Improved clinical use of Twin-block and Herbst as a result of
viscoelastic tissue forces on the condyle and fossa in treatment
and long–term retention: Growth relativity by John C
Voudouris and Kuftinec Mladen in AJO-DO 2000 Mar;117:247-
66

• Enlow D.H., Harris D.B.: A study of the postnatal growth of the

human mandible. Am J Orthod. 1964; 50: 25-50.

• Thilander B.: Basic mechanisms in craniofacial growth. Acta

Odontol Scand 1995; 53: 144-151.
Concepts Of
Growth &
Development

Nayanika Priyam
I year Post Graduate