Basic Concepts of
Growth Part-I
Samikshya Paudel
1st year Resident
Department of Orthodontics
Kantipur Dental College
Contents
• Introduction
• Importance
• Enlow’s concepts of growth
• Genes/Proteins involved in craniofacial growth
• Somatic growth
• Catch-up growth
• Growth: Pattern, Variability, Timing
• References
Introduction
Growth
• Increase in size, change in proportion and
progressive complexity
- WM Krogman (1950)
• Quantitative aspect of biologic development per
unit of time.
-RE Moyers (1988)
Growth
• Entire series of sequential anatomic and
physiological changes taking place from the
beginning of prenatal life to senility
-HV Meredith(1945)
• An increase in size or number.
-WR Proffit
(1986)
Development
• Progress towards maturity.
-TW Todd (1937)
• All the naturally occurring unidirectional changes in
the life of an individual from its existence as a
single cell to its elaboration as a multifunctional
unit terminating in death.
-RE Moyers
Development
• An increase in complexity. Development carries an
overtone of increasing specialization , so that one
price is a loss of potential.
• Growth is largely an anatomic phenomenon,
whereas development is physiologic and
behavioral.
- William R. Proffit
Importance
Facial morphogenesis is essential so that the
clinician can grasp:
Normal
Reasons
Abnormal
Diagnosis
&
Rationale treatment
planning
Biologic Retention
factors & relapse
Enlow’s Concepts of
Growth
Terms
• Growth center: Location at which independent
growth occurs
• Growth site: Mere location at which growth occurs
• Deposition – Addition of new bone to the bony
surface by osteoblastic activity
• Resorption – Removal of bone due to osteoclastic
activity
Terms
• Remodeling:
Reshaping of the outline of the bone by selective
resorption of bone in some areas and deposition in
other areas
• Displacement: Movement away from a certain
position or place
• Primary: Occurring in conjunction with bone’s own
growth and
• Secondary displacement: Caused by enlargement of
adjacent or remote bones or soft tissues; but not of
the bone itself
Terms
• Relocation:
The progressive, sequential movement of
component parts as a
bone enlarges.
• Drift: Relocation of bone by simultaneous
deposition and resorption processes on the
opposing periosteal and endosteal surfaces
Concept 1
• Facial growth and development is a morphogenic
process working toward a composite state of
aggregate structural and functional balance
among all of the multiple, regional growing and
changing hard and soft tissue parts.
Concept 2
• Bones grows by adding new bone tissue on one side
of a bony cortex and taking it away from the other
side.
• The surface facing toward the direction of progressive
growth receives new bone deposition (+).
• The surface facing away undergoes resorption(-).
• This composite process is termed as “drift”.
Concept 3
• The outside and inside surfaces of a bone are
completely blanketed by a mosaic-like pattern of
growth fields.
Concept 4
• Bone produced by the covering membrane
(periosteal bone”) constitutes about ½ of the
cortical bone tissue present; bone laid down by the
lining membrane (endosteal bone), makes up the
other half.
Concept 5
• Growth is not programmed within the calcified part
of the bone itself.
• The blue print for the design, construction, and
growth of a bone lies in the muscles, tongue, lips,
cheeks, integument, mucosae, connective tissues,
nerves, blood vessels, airway, pharynx, the brain
as an organ mass, tonsils, adenoids and so forth,
all of which provide information signals that pace a
bone’s development.
Concept 6
• All the various resorptive and depository growth
fields throughout a bone do not have the same rate
of growth activity.
• Some depository fields grow much more rapidly or
to a much greater extent than others.
• The same is true for resorptive fields.
• Fields that have some special significance or
noteworthy role in the growth process are often
called growth sites.
• However, growth does not occur just at special
growth sites, the entire bone participates actively
and directly.
Concept 7
• Remodeling is a basic part of the growth process.
• A bone must remodel during growth because its
regional parts become moved; drift moves each
part from one location to another as the whole
bone enlarges.
• This calls for sequential remodeling changes in the
shape and size of each region.
• Relocation is the basis for remodeling.
• As the mandible grows, whole ramus is relocated
posteriorly, and the posterior part of the
lengthening corpus becomes relocated into the
area previously occupied by the ramus.
• The corpus grows longer as a result.
• In the maxilla, the palate grows downward (that is,
becomes relocated inferiorly) by periosteal
resorption on the nasal side and periosteal
deposition on the oral side.
• This growth and remodeling process serves to
enlarge the nasal chambers.
Functions of Remodeling:
• Progressively enlarge each bone
• Sequentially relocate the component parts of whole bone for
overall enlargement
• Maintain shape of bone in accordance with the physiologic
actions exerted on that bone, to accommodate its various
functions
• Provide progressive fine-tuning fitting of all separate bones to
each other and to their contiguous, growing, functioning soft
tissues, and
• To carry out continuous regional structural adjustments of all
parts to adapt to the multiple intrinsic and extrinsic changes
in conditions.
Concept 8
• As a bone enlarges, it is simultaneously carried
away from other bones in direct contact with it.
This creates the ‘space’ within which bony
enlargement takes place.
• The process is termed primary displacement
(sometimes also called “translation”).
• The process of new bone deposition does not cause
displacement by pushing against the articular
contact surface of another bone.
• Rather, the bone is carried away by the expansive
forces of all the growing soft tissues surrounding it.
• As this takes place, new bone is added
immediately onto the contact surface, and the two
separate bones thereby remain in constant
articular junction.
The Nasomaxillary Complex:
In contact with the floor of cranium
• The whole maxillary region , in toto, is
displaced downward and forward
away from cranium by the expansive
growth of soft tissues in the midfacial
region.
• This triggers new bone growth at the
various sutural contact surfaces
between the nasomaxillary composite
and the cranial floor.
The Nasomaxillary Complex:
In contact with the floor of cranium
• Displacement thus proceeds downward and
forward as growth by bone deposition
simultaneously takes place in an opposite upward
and backward direction (that is, toward its contact
with the cranial floor).
• Similarly, whole mandible is displaced
‘away’ from the articulation in each
glenoid fossa by growth enlargement of
composite of soft tissues in the growing
face.
• As this occurs, condyle and ramus grow
upward and backward into the ‘space’
created by the displacement process.
• Note that the ramus ‘ remodels’ as it
relocates postero-superiorly.
• It also becomes longer and wider to
accommodate:
1) the increasing mass of masticatory
muscles inserted onto it,
2) The enlarged breadth of the
pharyngeal space and
3) The vertical lengthening of
nasomaxillary part of the growing face.
Concept 9
• A process of secondary displacement also occurs
during growth.
• Primary displacement, is associated with bone’s
own enlargement.
• Secondary displacement is the movement of a
whole bone caused by the separate enlargement of
other bones, which may be nearby or quite distant.
• For example: increase in size of the bones that
compose the middle cranial fossa (in conjunction
with growth of brain) result in a marked
displacement movement of the whole maxillary
complex anteriorly and inferiorly.
• This is quite independent of the growth and
enlargement of the maxilla itself. The displacement
effect is thereby of a secondary type.
• What happens deep in the cranial base, thus
affects the placement of the bones in the face.
• The effects of growth activities in relatively distant
locations are passed on, and one must take all
such changes into account when analyzing the
growth processes and the facial characteristics of
any individual person.
Concept 10
• Facial growth is a process that requires intimate
morphogenic interrelationships among all of its
component growing, changing, and functioning soft and
hard tissue parts.
• No part is developmentally independent and self-
contained; this is a fundamental and very important
principle of growth.
• The growth process works toward an ongoing state of
composite functional and structural equilibrium.
For eg:
If a premature fusion of some cranial sutures has resulted in
growth-retarded development of the naso-maxillary
complex
because the anterior endocranial fossae (a template for
midfacial development) have been foreshortened,
the altered nasomaxillary complex itself nonetheless has
grown in a balanced state relative to its basicranial
template,
even though abnormal in comparison with a population
norm.
• Craniofacial surgical correction attempting to more
or less create this norm can disturb the former
balance, and
• some degree of natural rebound can be expected
as growth attempts to restore the original state of
equilibrium among all of the regional parts
involved,
• since some extent of the original underlying
conditions can still exists that were not, or could
not be, altered clinically
Genes/proteins involved in Growth
• BMP-1 to BMP-9
• Dlx-1 to Dlx-6
• Fgf-1 to Fgf-18 and Fgfr-1 to Fgfr-3
• Growth hormone and growth hormone receptor
• Goosecoid gene
• Hoxa1 to Hoxa3
• Insulin-like growth factors
• Msx1 to Msx2
• Shh
• Tgfb1 to Tgfb3
Somatic Growth
• The growth and maturation of the body as a whole,
is somatic growth.
David S. Carlson and Peter H. Buschang
• It is highly correlated to growth of craniofacial
complex, thereby necessitating the study of
somatic growth.
• An individual’s growth is determined by various
determinants which falls in either: Genetic factors
or
Nutrition, Illness, injuries, racial
Environmental factors.
differences, socioeconomic
factors, exercise, Order of birth,
Secular trends
Canalised Growth
• Ideally, if an organism grew in an environment which is
feasible for unrestrained growth, growth would follow a
particular pre-defined curve, mostly dictated by genetic
make-up, until the final size and shape are reached just
as if growth were chanelled along a pre-defined canal.
• Waddington called this phenomenon canalization or
homeorrhesis (steady flow).
• This term was used to describe the growth seen in an
unrestrained environment. The growth of these children
followed or paralleled a particular centile just as if
growth were occurring at a pre-defined rate and form.
Catch-up Growth
• Since no individual grows in an unrestrained
environment, there is modulation of growth.
• Starting from birth, the child is exposed to the
outside environment. Thus, humoral and other
adjustments restrain temporary slowing of growth.
• Whenever the growth of an organism is hindered
due to environmental influences, the body tends to
respond by exaggerated growth session when the
circumstances become favourable. This
phenomenon is catch-up growth.
Growth: Pattern, Variability and
Timing
50% 30% 12%
Pattern : Refers to change in
proportional relationship
over time.
In the figure we can see the
change in overall body
proportions that occur during
normal growth and
development.
These changes are part of There is an axis of increased growth
normal growth pattern, and extending from head towards the feet.
reflects the cephalocaudal
gradient of growth.
Growth: Pattern
Another aspect: Not all
tissue systems of the body
grow at the same rate.
In the figure we can see the
four major tissue systems
of the body.
Differential growth
Growth: Pattern
A newborn skull compared with an adult one.
At birth, the face and jaws are relatively
underdeveloped compared with their extent in
the adult. As a result, there is much more
growth of facial than cranial growth post-
natally.
Growth: Variability
• All people are not alike in the way they grow.
• The clinician should decide whether any individual
is at the extreme of normal variation or falls
outside the normal range.
• Instead of categorizing into normal or abnormal, it
is useful to quantify the deviations from the usual
pattern.
Growth: Variability
For a child, such assessment
are made through growth
charts.
Growth charts are useful to
follow a child over time to
evaluate whether there is
marked change in growth
pattern.
Growth: Timing
• Variation in timing arise because the same event
happens for different individuals at different times,
growth spurt occurs at different times in different
individuals.
• Some grow rapidly and mature early, completing their
growth quickly and thereby appearing on the high side of
the development charts until their growth ceases, and
then their contemporaries begin to catch up.
Growth: Timing
References
• Enlow DH and Hans MG. Essentials of Facial Growth. Philadelphia: Saunders,
1996.
• Graber TM, Vanarsdall RL, Vig K. Orthodontics: Current principles and
techniques. 6th Ed. St. Louis: Mosby, 2017.
• Proffit WR, Fields HW, Larson B, Sarver DM. Contemporary orthodontics. 6th
Ed. Elsevier Health Sciences, 2018.
• Kharbanda OP. Clinical evaluation. Diagnosis and Management of
Malocclusion and Dentofacial Deformities. 2nd Ed. New Delhi: Elsevier India,
2013.
Thank you
