pre natal and post natal / orthodontic courses by indian dental academy
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Pre natal and post natal growth and development of nasomaxillary complex
INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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Growth and development of Nasomaxillary complexAnatomyPre natal growth Post natal growthClinical implications
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ANATOMY OF MAXILLA Two maxillae articulate to form
– 1. Whole upper jaw.– 2. Roof of oral cavity.– 3. Greater part of floor and
lateral wall of nasal cavity and part of nasal bridge.
– 4. Greater part of floor of each orbit.
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ANATOMY OF MAXILLA. PARTS OF MAXILLA.
– 1. BODY –LARGE AND PYRAMIDAL IN SHAPE.
– 2. FOUR PROCESSES. FRONTALZYGOMATICALVEOLAR
PALATINE
MAXILLA HOUSES THE LARGEST SINUS OF THE FACE THE MAXILLARY SINUS
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Palatine process[maxilla]
Maxillary sinus
Frontal process
Maxillary process [palatine]
Alveolar process
ANATOMY – MEDIAL VIEW
Horizontal plate of palatine
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Nasal notch
Zygomatic process
ANS
Alveolar process
ANATOMY-LATERAL VIEW
Frontal process
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Pre natal growth and development
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Pre-natal growth At fourth week of of IUL- 1.migration of neural crest cells 2.formation of brachial arches
STOMODEUM
FRONTONASAL
MAXILLARYMAXILLARY
MANDIBULAR MANDIBULARwww.indiandentalacademy.com
Medial nasal process
Lateral nasal process
Maxillary process
Mandibular process
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Maxillary and Mandibular processes- { first brachial arch} Frontonasal processes- { downward
proliferation of mesenchyme of developing brain}
Medial nasal Lateral nasal
Mesenchyme of first arch
maxilla
palatine
mandible
zygomatic
Part of temporalwww.indiandentalacademy.com
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
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AT SEVENTH WEEK IUL Primary ossification center -for each
maxilla at termination of infraorbital nerve above canine tooth dental lamina.
Secondary center zygomatic
orbitonasal
intermaxillarynasopalatine
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AT EIGHT WEEK IUL Intramembranous ossification centers
appear for;-Nasal and lacrimal bones.-Medial pterygoid plate of sphenoid.-Vomer.-Zygomatic bone
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Anteroposterior maxillo- mandibular relationship approaches that of newborn infant
Maxilla increases in height
BY TWELFTH WEEK
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FRIEBAND-{the growth of palate in human fetus}
1st trimester-narrow 2st trimester-moderate width 3st trimester- wide Breadth>length Height changes less dramatic
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Pre-natal Growth and development of palate
Formation of primary and secondary palate
Elevation of palatal shelves
Fusion of palatal shelves
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Early palate formation
28th day of IUL -disintegration of buccopharangeal
membrane -stomadeal chamber
Horizontal extensions
Oral cavity
Nasal cavity
2 palatal shelves
Single primary palate
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Structure of palate
PALATOGENESIS
Secondary palatePrimary palate
5 TH week IUL 12 TH week IUL6 9
CRITICAL PERIODwww.indiandentalacademy.com
Primary palateFrontonasal process
Medial nasal
mesenchyme
Wegde
Wedge shaped mass between internal surface of maxillary prominence
Primary palatePre-maxilla
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Primary palate
Primary palate
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Secondary palate
2 horizontal mesenchymal projections
Maxillary prominence
Lateral palatine process
Fuse-With each otherPrimary palate
Nasal septum
Secondary palatewww.indiandentalacademy.com
Secondary palate
PALATAL SHELVES
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Elevation of palatal shelves At 6 weeks1. Tongue {undifferentiated tissue} pushes dorsally2. palatal shelves become vertical3. Elevation occurs from vertical to
horizontal position
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Elevation of palate
Nasal septum
Palatal shelves
tongue
Histological section
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At 8 weeks
Elevation of palatal shelves
Muscular movement
Pressure differences
Biomechanical transformation
Intrinsic shelf force Differential
mitotic growthWithdrawal of embryo’s face
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Fusion of palatal shelves
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Fusion of the palatal shelves
In the closest union there is still some separate existence of component parts ; in the most complete separation there is some reminiscence of union Samuel Butler
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Fusion of palate
Incisive foramen
Mid palatine raphe
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Formation of palate[summary]Primordium of
Formed by
Derived from
Primary palate
Secondary palate
Pre maxilla
Hard and soft palate
Median palatine process
Lateral palatine process
Frontonasal process
Maxillary process
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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 11th week 2nd arch
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Growth in dimensions
Length - 7-8 weeks IUL Width - 4th month onwards
heightwidthlength
Arched palate
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Growth in dimensions
Pre natal life length > width
At birth length = width
Post natal life width > length
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Growth at mid palatal suture ceases at 1-2 years
Apposition inferior surface alveolar process Resorption –superior{nasal} surface
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V principle of Bang and Enlow
Entire ‘v’ shaped structure moves in a direction towards the wide end of the ‘v’
Remodeling of palate
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Factors affecting growth of palate
elevation of head and lower jaw Oxygen and nutritional deficiency Excess endocrine substances Drugs Irradiation vascularity
teratogens
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Elevation of head and lower jaw
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ANOMALIES OF PALATE Epithelial pearls
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ANOMALIES OF PALATE
Torus palatinus
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ANOMALIES OF THE PALATE
High arched palate
MARFANS SYNDROME
CROUZON SYNDROME
CLEIDOCRANIAL DYSOSTOSIS
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ANOMALIES OF PALATE
Cleft palate
Failure of fusion of the lateral palatine process with each other or with the median palatine process
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Genesis of cleft palate Delay in shelf elevation Disturbance in mechanism of shelf
elevation Failure of shelves to contact due to lack
of growth Failure to displace the tongue during
closure [Pierre Robin syndrome]
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Genesis of cleft palate
Failure to fuse after contact as epithelium does not break down
Rupture after fusion
defective merging
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Types of cleft palate
Bifid uvulaUnilateral cleft palate
Bilateral cleft palate
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Bilateral cleft palate
Bifid uvula
Unilateral cleft palate
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Etiology of cleft palate
Infectious agents
irradiation drugs
Nutritional deficiency
Excess hormones
Smoking and alcohol
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Clinical features of cleft palate Feeding problems particularly in infants
in whom suckling process demands intact palate
Nasal regurgitation/nasal twang in voice
Collapsed arch
Difficulty in speech and swallowing
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Post natal growth of maxilla
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Post natal growth of maxilla
Surface remodeling
displacement
CRANIAL BASE MAXILLA
apposition resorption
MOSS
TRANSPOSITION
TRANSLATION
SUTURES
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Post natal growth of maxilla
Surface apposition Sutural growth nasal septum growth Spheno occipital synchondrosis
In contrast to cranial base maxilla is dominated by intra membranous ossification
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Surface apposition
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Sutural growth
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Spheno occipital synchondroses
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Post natal growth of maxilla
Growth in height vertical
Growth in width transverse
Growth in length A - P
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HEIGHT
DEPOSITION ON THE ORAL SIDE
RESORPTION ON THE NASAL SIDE
ENLOW AND BANG ‘V’ PRINCIPLE
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Sagittal view Coronal view
HEIGHT - ‘V’ PRINCIPLE
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HEIGHT
APPOSITION IN THE ALVEOLAR PROCESS
ERUPTION OF TEETHwww.indiandentalacademy.com
Primary displacement
HEIGHT
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PRIMARY DISPLACEMENT
SUTURAL THEORY
CARTILAGENOUS THEORY
FUNCTIONAL MATRIX HYPOTHESIS
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SUTURAL THEORY
SUTURES HAVE INNATE GROWTH POTENTIAL
OBLIQUE NATURE
SLIDING EFFECT
SICHER
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CARTILAGENOUS THEORY
NASAL SEPTUM –INNATE GROWTH POTENTIAL
THRUST EFFECT– SEPTOPREMAXILLARY LIGAMENT
MORE ROLE IN A-P THAN VERTICAL
SURGICAL REMOVAL OF NASAL SEPTUM
SCOTT
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Removal of nasal septum –mid face deficiency
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FUNCTIONAL MATRIX HYPOTHESIS
BASAL BODY INFRAORBITAL
NERVE
ORBITAL UNIT EYEBALL
NASAL UNIT SEPTAL CARTILAGE
ALVEOLAR UNIT TEETH
MOSS
SKELETAL UNITS FUNCTIONAL MATRIX
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FUNCTIONAL MATRIX HYPOTHESIS
HEIGHT
ENLARGING ORO FACIAL CAPSULE
REMODELING CHANGES IN THE ORBIT
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WIDTH Finished earlier in postnatal life
WIDTH GROWTH IN MID PALATINE SUTURE
REMODELING IN THE LATERAL SURFACE OF ALVEOLAR PROCESS
Mutual transverse rotations of maxillary halves give palate ‘u’ shape
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LENGTH Begins rapidly in the 2 nd year of life
Maxillary tuberosity
Palato -
maxillary suture
primary secondary
displacementwww.indiandentalacademy.com
QUANTITATION OF MAXILLARY REMODELING
Uniform displacement of all 3 pts in vertical direction [downward displacement –0.3mm/year]
Horizontal direction posterior displacement of all 3 pts [however the displacement of PNS was greater than ANS and pt A ]
THE INCREASE IN LENGTH IS PRIMARILY BECAUSE OF GROWTH IN POSTERIOR BORDER
Sheldon Baumrind,Edward Korn
AJO JAN 1987
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Maxillary tuberosity Established by the posterior boundary
of anterior cranial fossa Helps in posterior and horizontal
lengthening of arch
Anterior displacement
= posterior lengthening
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Key ridge
Reversal occurs at the key ridge
Posterior - apposition
Anterior - resorption
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Maxillary sinus PRE NATAL lateral evagination of mucous
membrane in middle meatus –3rd month IUL
AT BIRTH 2mm -long, 1mm in width + height PNEUMATISATION
PRIMARY SECONDARYwww.indiandentalacademy.com
Maxillary sinus
AGE CHANGES
Expands - 2mm vertically 3mm A-P - every year
> in size - resorption in walls + alveolus
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Maxillary sinus
POST NATAL All internal surfaces
resorption[expect medial]
Rapid continues downward growth
close proximity to buccal maxillary teeth
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Zygomatic region
Posterior relocation
anterior posterior
Increase in height
frontozygomatic Inferior border
Lateral growth
displacementZygomaticotemporal [anterior]
Frontozygomatic [inferior]www.indiandentalacademy.com
Nasal airway
Lining surface of bony wall and floor resorptive
Downward relocation of palate
Lateral and anterior expansion
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Nasal airway Ethmoidal
conchae lateral + inferior
depositionmedial + superior
resorption
Inter nasal septum
Lengthens vertically at sutural junctions
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Clinical Implications and Summary
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Pre natal growth
Formation of germ layers
Day 17 Fetal alcohol syndrome
[mid face deficiency]
Migration and proliferation of cell population
Day 19-28Treacher Collin syndrome
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Pre natal growth
Primary palate formation
28-38 days
Cleft lip /cleft palate other facial clefts
Secondary palate formation
42-55 days
Cleft palate/synostosis
CROUZON syndrome
Epithelial pearls
Torus palatinus
high arched palatewww.indiandentalacademy.com
Post natal growth
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Post natal growth AT BIRTH
Hard palate : length = width
maxillary sinus : not visible radiographically
1 – 2 years
Extensive remodeling descent of palate /enlargement of nasal cavity
Mid palatine suture growth ceases
No synostosiswww.indiandentalacademy.com
Post natal growthTHE MIXED DENTITION YEARS
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Post natal growth
mid palatine suture starts closing at 9- 10 years
RME BEST DONE BETWEEN 9-14 yrs
THE MIXED DENTITION YEARS
Growth in width of the dental arch anterior to the first molar
Ceases by 5-6 yrs
Inter canine width completed
12 yrs - females
18 yrs - males
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Post natal growth
THE DEPOSITORY GROWTH POTENTIAL OF TUBEROSITY ALLOWS FOR ARCH EXPANSION BY MOVING THE TEETH POSTERIORLY INTO THE AREA OF BONE DEPOSITION
EXTENSIVE SCOPE FOR GROWTH
MODIFICATION BEFORE ADOLESCENT GROWTH SPURT
THE MIXED DENTITION YEARS
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Post Natal Growth THE EARLY PERMANENT DENTITION YEARS
•Growth modification still possible in boys
•RME can still be tried till 12 -15 yrs
•>15 years complete closure[synostosis]
Orthognatic surgerywww.indiandentalacademy.com
Age changes All para nasal sinuses increase in size Vertical height decreases
Vertical changes > AP > width Soft tissue changes > skeletal Nose growth continues till 25 years Inclination of palatal plane
increases[post downwards]
Alveolar process resorbed
Tooth loss
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References Contemporary orthodontics- PROFFIT Principles and practice of orthodontics –
GRABER Essentials of facial growth- ENLOW Craniofacial embryology- SPERBER The developing human-KEITH MOORE oral histology and embryology-
TENCATE Handbook of orthodontics-MOYERS
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References quantitation of maxillary remodeling-S
BAUMRIND ,E KORN –AJO JAN 97 Dentistry for child and adolescent-MAC
DONALD Clinical pedodontics-FINN Color atlas of Embryology
MOORE,PERSUAD Clinical oral pathology-
NEWILLE ,WHITE Diseases of oral mucosa-
BORK,HOEDEwww.indiandentalacademy.com
Thank you
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