GROWTH OF THE NASOMAXILLARY COMPLEX
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Contents - Anatomy of maxilla - Prenatal & postnatal development - Growth of : Zygomatic region Palate Maxillary tuberosity Lacrimal suture Nasal airway Max. sinus Orbit - Clinical implication of maxillary growth www.indiandentalacademy.com
Anatomy:  The maxillary bone is the second largest bone of face, the first being mandible.  The maxillary bones are two in number and when two maxillae articulate, they form: a. Whole upper jaw. b. Roof of oral cavity. www.indiandentalacademy.com
c. Greater part of floor and lateral wall of nasal cavity and part of bridge of nose. d. Greater part of floor of each orbit. www.indiandentalacademy.com
Body Large and Pyramidal in shape. Four processes Frontal Alveolar Zygomatic Palatine www.indiandentalacademy.com
ďƒ˜Body of maxilla is like a hollow pyramid. ďƒ˜Base of pyramid is formed by nasal surface and apex is directed towards zygomatic process.
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Frontal Process Maxillary sinus Maxillary process [palatine] Horizontal plate of palatine process of maxilla Alveolar process
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Sites of attachment surrounding bones:
of
maxilla
to
1. By pterygomaxillary fissure and pterygopalatine fossa between sphenoid bone of cranial base and palatine bones or maxillary bones or posterior face.
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2. The zygomatic bone is attached to calvaria at temporozygomatic and frontozygomatic suture.
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3. The maxillary bone and nasal bones are attached to calvaria at frontomaxillary and frontonasal sutures.
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PRENATAL DEVELOPMENT MAXILLA
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OF
Face
Upper
Frontonasal Prominence
Middle
Maxillary prominence www.indiandentalacademy.com
Lower
Mandibular Prominence
Head development depends upon inductive activity of prosencephalic and rhombencephalic organizing centers. Prosencephalic Upper third of face. Rhombencephalic lower third of face.
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Middle
and
ďƒ˜The branchial arches begin to develop early in 4th week due to migration of Neural Crest Cells into future head and neck region.
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The five facial primordia appear around the stomodeum or primitive mouth early in 4th week. 1. The frontonasal prominence ďƒ Forms cranial boundary of stomodeum. 2. Paired maxillary prominences ďƒ Lateral boundary of stomodeum.
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3. Paired mandibular prominences ďƒ Caudal boundary of stomodeum.
Frontonasal prominence Maxillary prominence Mandibular prominence www.indiandentalacademy.com
By the end of 4th week each side of the inferior part of frontonasal prominence. bilateral oval thickenings of surface ectoderm mesenchyme proliferates producing horseshoe shaped elevations
Medial Nasal Prominence
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Lateral Nasal Prominence
The maxillary prominences enlarge. grow medially towards each other and towards the medial nasal prominences. moves the medial nasal prominences towards median plane and towards each other. Each lateral nasal prominence is separated from maxillary prominence by a cleft or furrow called as Nasolacrimal groove. www.indiandentalacademy.com
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By the end of 5th week.
Maxillary prominence + lateral nasal prominence
continuity between side of nose and cheek region.
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The facial bones develop intramembranously from ossification centers in embryonic facial prominences. 1) In the frontonasal prominence –single center appear in 8th week for each of - nasal and - lacrimal bone www.indiandentalacademy.com
2) In maxillary prominences numerous intramembranously ossification centers develop. - in 7th week IU & - in 8th week IU
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a)
In 7th week I.U.
1) Primary IM ossification center for each maxilla appears at termination of infraorbital nerve just above the canine tooth dental lamina. 2) Secondary zygomatic, orbitonasal, nasopalatine and intermaxillary centres appear and they fuse with primary centre. www.indiandentalacademy.com
3)Two intermaxillary ossification centres generate -alveolar ridge -primary palate region.
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In 8th week I.U. Ossification centers for - Medial pterygoid plates of sphenoid. - Vomer - And also single centre for each of zygomatic bone appears. www.indiandentalacademy.com
ď Ž
ď Ž
Growth of maxilla depends upon influence of several functional matrices These act upon different areas of bone
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Skeletal Units of Maxilla -- Related skeletal units 1. Basal body Infraorbital nerve. 2. Orbital unit Eye ball. 3. Nasal unit Septal cartilage. 4. Alveolar unit Teeth.
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POST NATAL GROWTH AND DEVELOPMENT OF MAXILLA
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As in other regions of the craniofacial skeleton, growth in maxilla occurs by 2 processes: 1. Appositional and resorptional surface remodeling. 2. Displacement Moss referred to these movements as transposition and translation respectively. www.indiandentalacademy.com
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Enlow and Bang has described the growth of maxilla by way of it’s sutures that attach it to the cranial base, by applying the principle of “Area Relocation” - (i.e. specific local areas come to occupy new actual positions in succession, as the entire bone enlarges, involving both the processes, translation and transposition). www.indiandentalacademy.com
For the precise assessment of remodelling processes 2 methods have been used: 1. Cross sectional study using histological sections of dried skulls. 2. Longitudinal studies using implant markers and Cephalometric radiographs. Bjork was the first to use this technique in 1955. In the first technique it was difficult to note the individual variability in the growth amount and rate. www.indiandentalacademy.com
Postnatal growth of maxilla is mainly because of: 1. Surface apposition. 2. Sutural growth. 3. Nasal septal growth. 4. Sphenooccipital synchondroses.
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Growth of maxilla can be viewed in 3 aspects: 1. Growth in the Height. . 2. Growth in the transverse direction. 3. Growth in the anterio-posterior direction. www.indiandentalacademy.com
1. Growth in the Height. a) Enlow & Bang V principle b) Surface remodelling -alvelar pr. -orbit c) Displacement process -primary -secondary
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1) GROWTH IN HEIGHT a).In the coronal section, the palate is ‘V’ shaped. Applying the Enlow and Bang’s ‘V’ principleDeposition on oral side.
Resorption on nasal side.
Increases the height of the nasal cavity. www.indiandentalacademy.com
V principle in sagittal and coronal view
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b) Similarly surface remodeling of bone in the alveolar process, which increases the height of palatal vault. - Increase in height of maxilla also occurs because of remodelling changes in orbit
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c) In addition to surface remodeling the height of maxilla is increased by displacement process i.e. primary and secondary.
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Primary Displacement Primary displacement because of apposition at the tuberosity and palatine sutures which pushes the maxilla in a forward direction, thus separating the sutures and further, causing bone apposition in the connective tissue.
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Primary displacement
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The increase in height of maxilla because of primary displacement can be explained on the basis of
Sutural theory
cartilaginous theory Functional hypothesis www.indiandentalacademy.com
Sutural theory explaining the maxillary growth
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Animal and human studies showing the effect of removal of nasal septum on the growth of the midface
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Secondary Displacement Secondary displacement occurs because of growth of the anterior and middle cranial fossa and changes in cranial base flexures. (Also because of increase in length of cranial base).
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Secondary displacement
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2) Growth in Transverse Direction: It is finished earlier in postnatal life. Occurs by two processes:
Alveolar remodeling in the lateral surface of alveolar process
Growth of the midpalatine suture
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Growth of the mid-palatine suture
Occurs in response to the functional matrix
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Mutual transverse rotations separate the posterior region more than the anterior U shaped arch
3) Growth in anteroposterior direction: -- Begins in the 2nd year of life and ceases after the increase in width has taken place. --Occurs by a) Surface remodeling -in the maxillary tuberosity region (i.e. appositional changes) -and in the sutures between the palate and the palatine bones. www.indiandentalacademy.com
Palato maxillary suture
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b) Cortical drift – The anterior surface of the maxilla is mostly resorptive, however, the total growth of the maxilla is seen to be in an antero-inferior direction. This is because as the maxilla remodels, it is simultaneously translated in an antero-inferior direction.
- Thus, it is both the remodeling and translatory growth process (primary& secondary displasement), which brings about the change in anteroposterior direction. www.indiandentalacademy.com
The antero-inferior displacement of maxilla
Sutures
nasal septum, sphenooccipital synchondrosis
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the orofacial functional matrix
Discussion of the study conducted by Sheldon Baumrind (AJO Jan, 87).
In their study, they used implant markers and computer aided methods for analyzing the lateral skull radiographs.
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They used 3 reference points. ANS, PNS and Point A. 1)Found out that there was a uniform displacement of all the 3 points in the vertical direction. On an average, the mean downward displacement was not more than about 0.3mm / year. www.indiandentalacademy.com
2) In the horizontal direction, there was a posterior displacement of all the 3 landmarks. ď Ž The displacement of PNS was greater than point A and ANS. ď Ž Thus this finding proves that the increase in length of hard palate is primarily by growth at the posterior border. www.indiandentalacademy.com
3)The backward and downward remodeling of all the 3 landmarks is reduced after about 13.5 years. This finding was consistent with the cross-sectional studies on dry skull.
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Growth of Zygomatic region
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The malar region
anterior surface
Posterior surface
Resorption
Apposition
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Posterior remodeling is basically to keep pace and close contact relation with the maxillary bone. The magnitude of relocation is less as compared to the maxilla. It ceases after increase in dental arch length is achieved, during childhood. www.indiandentalacademy.com
Bone deposition
inferior edge of the zygoma
the fronto-zygomatic suture
vertical growth / increase in the height of the anterior part of zygomatic arch and the
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increase in vertical length of lateral orbital rim.
The lateral growth of the zygomatic region.
resorption on the inner aspect of zygoma.
periosteal deposition on the lateral surface of zygoma.
Enlarges the temporal fossa and keeps the cheek bone in proper proportion to the enlarging face. www.indiandentalacademy.com
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ďƒ˜ The antero-inferior displacement of the zygoma occurs simultaneously along with the maxilla and the magnitude is also the same. This is basically because of primary displacement of maxilla.
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Zygoma
displaced anteriorly
zygomaticotemporal suture
displaced inferiorly
frontozygomatic suture
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Growth and Development of Palate
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Oral development in the embryo begins by the appearance of the prechordal plate in the bilaminar germ disk on 14th day of development. The face derives from 5 prominences that surround central depression - the stomodeum that constitutes the future mouth. www.indiandentalacademy.com
The 5 prominences are: 1. The single frontonasal prominence. 2. The paired maxillary prominences 3. The paired mandibular prominences.
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Primitive stomodeum Oronasopharyngeal chamber 28thday
Oropharyngeal membrane disintegrates.
Continuity of passage between mouth and pharynx.
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Frontonasal and maxillary prominences
Entrance into gut
Horizontal extensions Oral cavity
Nasal cavity
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Horizontal extensions of Maxillary prominence
Frontonasal prominence
Primary palate
Central part of upper lip(tuberculum) www.indiandentalacademy.com
Lateral shelves
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Structure of Palate Palate
Primary palate
Secondary palate
Palatogenesis 5th week I.U to 12th week I.U. Critical period end of the 6th week until the beginning of the 9th week. www.indiandentalacademy.com
The Primary Palate
primary palate or median palatine process.
a wedge shaped mass of mesenchyme between the internal surfaces of the maxillary prominences of the developing maxilla.
deep (internal) part of the intermaxillary segment.
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Primary palate
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The primary palate becomes the premaxillary part of the maxilla, which lodges the incisors. The primary palate gives rise to only a very small part of the adult hard palate (i.e. the part anterior to the incisive foramen).
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The Secondary Palate internal aspects of the maxillary prominences two horizontal mesenchymal projections lateral palatine processes Secondary Palate www.indiandentalacademy.com
Secondary palate
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the lateral palatine processes elongate and move to a horizontal position. Lateral palatine processes
Nasal septum
Primary palate
fusion ventrally or anteriorly during the 9th week.
dorsally or posteriorly in the region of the uvula by the 12th week.
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Formation and Elevation of palatal shelves: The development of the tongue fills the oronasal chamber intervening between the lateral palatal shelves. At 6 weeks, tongue is a small mass of undifferentiated tissue, palatal shelves develop in a wedge shape and, because of the presence of the tongue, grow downward into the floor of the mouth along either side of the tongue.
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At 8 ½ weeks, the steps in the palatal development result in the movement of the palatal shelves from a vertical position beside the tongue to a horizontal position overlying the tongue.
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Nasal septum Palatal shelf Tongue
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Nasal septum Palatal shelf Tongue www.indiandentalacademy.com
This change in the position probably involves movement of both the tongue and palatal shelves. Several mechanisms have been proposed for this rapid elevation of the palatal shelves. 1. Biochemical transformations of the connective matrix of the shelves. 2. Variations in vasculature and blood flow to these structures. 3. A sudden increase in their tissue trigger. www.indiandentalacademy.com
4. Rapid differential mitotic growth. 5. An intrinsic shelf force. 6. Muscular movement. 7. The withdrawal of the embryo’s face from against the heart prominence by uprighting of the head facilitate jaw opening which in turn helps in elevation of palatal shelves www.indiandentalacademy.com
8. Pressure differences between the nasal and oral regions due to tongue muscle contractions may account for palatal shelf elevation. 9. The nerve supply to the tongue is sufficiently developed to provide some neuromuscular guidance to the intricate activity of palatal elevation followed by closure. www.indiandentalacademy.com
Fusion of the Palatal Shelves: During palatal closure i.e. following palatal elevation. The mandible becomes more prognathic. The vertical dimension of the stomodeal chamber increases. www.indiandentalacademy.com
Maxillary width remains stable, allowing shelf contact to occur. Also forward growth of Meckel’s cartilage relocates the tongue more anteriorly, depressing downward and laterally thus pushing the palatal shelves slide medially. www.indiandentalacademy.com
ďƒ˜Epithelial adherence between contacting palatal shelves is facilitated by degeneration of the epithelial cells and a surface coat accumulation of glycoproteins. ďƒ˜Only the medial edge of the epithelium of the palatal shelves (in contrast to their oral and nasal epithelia) undergoes cytodifferentiation involving a decline of epidermal growth factors receptors that lead to programmed cell death .This is essential for mesenchymal coalescence of 2 shelves. www.indiandentalacademy.com
ďƒ˜Fusion of the 3 palatal components initially produces a flat, unarched roof to the mouth. ďƒ˜ The fusing lateral palatal shelves overlap the anterior primary palate. ďƒ˜The site of junction of the 3 palatal components is marked by the incisive papilla overlying the incisive canal. www.indiandentalacademy.com
Incisive foramen
Mid palatine suture/raphe
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Mid palatine suture/raphe
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The line of fusion of the lateral palatal shelves is traced in the adult by the midpalatal suture and on the surface by the midline raphe of the hard palate..
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Growth in the Dimensions of the Palate: The hard palate grows in length, breadth, and height becoming an arched palate. The fetal palate increases in length more rapidly than in width between 7th and 18th week intrauterine and widening occurs from 4 th month onward. www.indiandentalacademy.com
In early prenatal life the palate is relatively long, but from the 4th month IU it widens as a result of midpalatal sutural growth and appositional growth along the lateral alveolar margin. At birth the length and breadth of the hard palate are almost equal. The postnatal increase in palatal length is due to appositional growth in the maxillary tuberosity region. www.indiandentalacademy.com
During infancy and childhood bone apposition occurs on the entire inferior surface of the palate and superior (nasal) surface undergoes resorption. This remodeling results in descent of palate and enlargement of the nasal cavity (i.e. to keep pace with the increasing respiratory requirements). www.indiandentalacademy.com
The appositional growth of the alveolar processes contributes to deepening and widening of the vault of the bony palate and also increases the height and width of palate. A variable number of transverse palatal rugae develop in the mucosa covering hard palate. They appear even before the fusion, which occurs at 56 days intrauterine. www.indiandentalacademy.com
‘V’ Principle of Bang and Enlow in the Remodelling of the Palate: As mentioned earlier the palate grows in an inferior direction by subperiosteal bone deposition on its entire oral surface and corresponding resorptive removal on the opposite side. The entire ‘V’ shaped structure thereby moves in a direction towards the wide end of the ‘V’ and increases in the overall size at the same time. www.indiandentalacademy.com
V principle in sagittal and coronal view
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Anomalies of Palatal Development: 1.Epithelial Pearls: Entrapment of epithelial rest or pearls in the line of fusion of the palatal shelves, (particularly in the midline) gives rise to median palatal rest cysts.
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Epithelial pearls
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2. Delay in elevation of palatal shelves from vertical to the horizontal while head is growing results in widening gap between the shelves so they cannot meet leading to cleft of the palate. Variations in Clefting of Palate: Cleft palate is part of number of syndromes like Mandibulofacial dysostosis (Treacher Collin Syndrome), Micrognathia (Pierre Robbin Syndrome) and Orodigito facial dysostosis. www.indiandentalacademy.com
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3. High arched palate seen in Marfan’s Syndrome, Cleidocranial dysostosis, Crouzon syndrome. 4. Torus Palatinus – Genetic anomaly of the palate is a localized mid palatal overgrowth of bone of varying size. If prominent, may interfere with the seating of removable Orthodontic appliance or upper denture. www.indiandentalacademy.com
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MAXILLARY TUBEROSITY
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Maxillary tuberosity helps in horizontal lengthening of the bony maxillary arch.
Maxillary growth in posterior direction. Remodeling at the tuberosity region produces the lengthening. www.indiandentalacademy.com
Tuberosity grows posteriorly lateral surface +++ Maxilla carried anteriorly
endosteal side of the +++ cortex(interior surface) Arch --widening
Maxillary Sinus increases in size www.indiandentalacademy.com
Cortex moves posteriorly and laterally
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Clinical Significance: 1. The depository growth potential of the tuberosity allows the clinician to expand the arch by moving the teeth posteriorly into the area of bone deposition. 2. In a Class II molar relation, such distal molar movement aid in achieving the treatment goal of a Class I molar relationship. ssss
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Lacrimal Suture
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Lacrimal bone is a diminutive flake of a bony island with its entire perimeter bounded by sutural connective tissue contacts, separating it from the many other surrounding bones.
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Lacrimal Suture
Collagenous linkage within sutural cartilage. Slippage of bones along perilacrimal sutural interface.
Maxilla displaced inferiorly. www.indiandentalacademy.com
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Remodeling Rotation of Lacrimal bone
Medial superior part
Inferior part
Remains with lesser expanding nasal bridge.
Moves markedly outward to keep pace with expansion of ethmoidal sinuses.
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Nasal Airway
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Nasal Airway resorption
deposition
lining surface of the bony wall and floor
nasal side of the olfactory fossae
lateral and anterior expansion of the nasal chamber
downward relocation of the palate
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Ethmoidal Conchae deposition
resorption
lateral and inferior sides
superior and medial surface
downward and lateral movement www.indiandentalacademy.com
Inter Nasal Septum Bony portion
lengthens vertically at its sutural junctions.
wraps in relation to variable amounts and directions of septal deviation.
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Individually variable remodeling changes are seen and the thin plate of bone show alternate fields of deposition and resorption on right and left sides producing a buckling to one side or the other.
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MAXILLARY SINUS
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MAXILLARY SINUS
The largest of paranasal sinuses.
Pyramidal cavity in the body of the maxilla.
Borders Antero-Posteriorly posterior to roots of maxillary canine
area of 3rd molar www.indiandentalacademy.com
Supero Inferiorly Root tips of maxillary posterior teeth.
Floor of the orbital cavity. Communication:
maxillary ostium Posterior part of the hiatus in the middle meatus. www.indiandentalacademy.com
Functions: Imparts resonance to the voice during speech. Lightens the skull or overall bone weight by being hollowed cavities. Warms the air as it passes into respiratory system. www.indiandentalacademy.com
Growth of Maxillary Sinus PRENATAL
AT BIRTH
3rd month I.U Lateral evagination or pouch of mucous membrane of the middle meatus of the nose.
Shallow cavity 2cm A-P in length,1cm in width and 1cm in height.
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Primary pneumatisation ďƒ early paranasal sinuses expand into the cartilage walls and root of the nasal fossae by growth of mucous membrane sacs into maxillary, sphenoid, frontal and ethmoid bones. Starts in 10 weeks I.U from the middle meatus.
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• Secondary Pneumatization sinus enlarges into bone from their initial small outpocketing always retaining communication with nasal fossa through ostia.. • Starts in the 5th month I.U
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Postnatal Growth Maxillary Sinus resorption
deposition
maxillary internal walls (except medially)
medial wall nasal surface resorption ↑ Nasal Cavity
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The rapid and continuous downward growth of this sinus after birth brings its walls in close proximity to the roots of buccal maxillary teeth and its floor below its osteal opening.
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ďƒ˜As each tooth erupt, the vacated bone becomes pneumatised by the expanding maxillary sinus whose floor descends from its prenatal level above the nasal floor to its adult level below nasal floor. ďƒ˜Into adult hood the roots of molar teeth commonly project into sinus lumen. www.indiandentalacademy.com
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Size: Average sinus is 7mm in length and 4mm in height & width and it expands 2mm vertically and 3mm anteroposteriorly each year.
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ORBITAL GROWTH
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ORBITAL GROWTH Orbit
Greater and Lesser wings of Sphenoid
Maxilla Ethmoid
Zygomatic
Lacrimal Frontal www.indiandentalacademy.com
Growth of the Orbit
Remodeling growth
Displacement among bony elements www.indiandentalacademy.com
Orbit deposition Floor
Roof Lining remodels
anteriorly and inferiorly
Frontal lobe of the cerebrum expands forward and downward
resorption on endocranial side and deposition on the orbital side.
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Remodeling changes in the orbital region
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The growth of the orbit can be explained as: i. Orbit grows by ‘V’ principle The cone shaped orbital cavity moves (relocation to remodeling) in a direction towards its wide opening. Deposits on the inside, thus enlarge the volume rather than reducing it. www.indiandentalacademy.com
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ii. Enlarging involved.
displacement
is
directly
Sutural bone growth at the many sutures within and outside the orbit. Orbital floor is displaced and enlarges in progressive downward and forward direction along with the rest of maxillary complex. www.indiandentalacademy.com
Studies by Enlow, Bang and Bjork have shown that in addition to the lowering of the nasal floor by downward growth displacement of the maxillary body, the nasal floor is further lowered by resorption and apposition taking place on the oral surface of hard palate.
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The floor of the nasal cavity in adults is positioned much lower than floor of the orbital cavity, whereas in child they are at the same level..
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Clinical Implications Of Maxillary Growth
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Cessation of maxillary growth in 3 planes of space is in the following order: 1. 2.
Tranverse Anterio-posterior
3.
Vertical www.indiandentalacademy.com
Transverse growth of maxilla In narrow palatal vault posterior cross bites are usually seen.
Skeletal
Dental www.indiandentalacademy.com
Skeletal
Unilateral
Bilateral
Present in CO and CR
present at centric occlusion but not in centric relation
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Dental crossbite
Quadhelix
‘W’ arch Cross elastics Archwire to some extent www.indiandentalacademy.com
Anteroposterior maxilla
growth
of
Class II skeletal malocclusion can be due to 3 reasons 1. 2. 3.
Prognathic maxilla. Deficient mandible. Or combination.
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Maxillary excess
Head gear
Cervical HG
Functional appliances
Occipital HG
Removable
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Fixed
Removable
Activator
Bionator
Twin Block
Fixed
Herbst
Jasper Jumper www.indiandentalacademy.com
Maxillary deficiency
Face Mask
Petit
Reverse pull Reverse head gear functional appliance
Delaire Class II frankel
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Twin blocks
Vertical growth of maxilla Long face Class II treatment
HP headgear to functional appliance Bite blocks on functional appliance
High pull head gear to molar. High pull headgear to maxillary splint
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References 1.Contemporary Orthodontics-William R. Profitt 2.Human Anatomy-Gray 3.Facial Growth-Enlow 4.Human Embryology-Sperber
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5. Quantitation of maxillary remodeling (A description of osseous changes relative to superimposition on metallic implants) AJO1987:Baumrind, Korn,and Ben-Bassat 6. Oral Orthopaedics And Orthodontics for Cleft Lip And Palate.-N.R.E Robertson
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