Theories of

growth
Dr.Sandeep
1 st Yr Post Graduate Trainee
Dept.Of Orthodontics And Dentofacial
Orthopaedics
SVS Institute Of Dental Sciences
 CONTENT
S
 Introduction
 Definitions
Theories of growth
 Remodeling theory of craniofacial
growth
 Genetic theory
 Sutural theory
 Cartilaginous theory
 Functional matrix theory
 Van Limborgh’s theory
 Enlow’s expanding ‘v’ principle
 Enlow’s counterpart principle
 Neurotrophic process in oro facial
growth
 INTRODUCTIO
N
Studying the normal changes that occur in the facial
complex is a very important to identify and diagnose
any existing abnormalities to provide optimal
treatment to the patient.
 It is essential for dental surgeon to know how face
changes, where changes occur, when these changes
usually takes place.
Evolution of theories
 Theories of
growth
 Remodeling theory of craniofacial growth
 Genetic theory
 Sutural theory
 Cartilaginous theory
 Functional matrix theory
 Van Limborgh’s theory
 Enlow’s expanding ‘v’ principle
 Enlow’s counterpart principle
 Neurotrophic process in oro facial growth
 Servosystem Theory of Craniofacial Growth
Remodeling theory of craniofacial growth
 Brash 1930s
 First general theory of carniofacial growth.
 According to this theory , remodeling occurs exclusively by
bone remodeling by

selective addition &resorption of bone at

sutures and cartilages.
Genetic theory
Brodie 1941
All growth is controlled by genetic influence and it is
Preplanned and pre-programmed.
This is one of the earliest theories put forward.
Role of genetic tissues in growth is controlled by
epigenetic influences from other tissue groups.
Genetic theory
Homeobox genes which helps in the establishment
of body plan , pattern formation and
morphogenesis.
Allapat et al , Msx homeo box gene family and craniofacial development . Cell res 13:429-
442,2003
Beta genes is responsible for the regulating cell
growth and organ development.
Dixon et al , fundamental of craniofacial growth .Boca raton,Fla:Crc press 1997
Sutural theory
Sicher 1955
Sicher believed that craino-facial growth occurs
at the sutures.
According to him paired parallel sutures that
attach facial areas to the skull and cranial base
region push the naso-maxillary complex
forwards to pace its growth with that of the
mandible.
A number of points were raised against this theory .
1 Area of suture is transplanted

Another location
(To a pouch in abdomen)

Tissue does not continue to grow.

 This indicates a lack of innate growth potential of the

sutures.
2. Growth takes place in untreated cases of cleft
palate even in the absence of sutures.

No significant difference could be found between height and

weight of cleft patients versus that of the normal population.
Saudi Medical Journal 2002; Vol. 23 (7): 823-827
3. Microcephaly and hydrocephaly raised doubts about
the genetic stimulus of sutures.

4. If a suture is compressed , growth at that site will be

impeded.
suture must be considered as areas that react, not the
primary determinants.
Clinical implications :
Sutures are secondary sites of bone growth that are
highly responsive to expansion of the cranial vault
and to functional and orthopaedic manipulations
of the growing maxillary complex. 
Cartilaginous theory
James scott, 1953
According to him intrinsic growth controlling factors
are present in cartilage and periosteum with sutures
being only secondary.
Through comparative histological analysis, Scott
concluded that the nasal septum is most active and
important for craniofacial skeletal growth through
approximately three to four years of age in humans.
During that time, the anterior-inferior growth of the
nasal septal cartilage, which is buttressed against
the cranial base posteriorly, “drives” the midface
downward and forward.
According to scott ,nasal septal cartilage is
pacemaker for the growth of entire naso-maxillary
complex.
The mandible is considered as diaphysis of a long
bone bent into horse shoe shape with epiphysis
removed, so that cartilage representing ‘half an
epiphysis plate at the end which represents the
mandibular condylar cartilage
Cartilage at the condyle should be act as a growth
center
whose growth forces the mandible downward and
forward, away from the cranial base.
Points in favour of this theory :
1. In many bones ,cartilage growth occurs, while bone
merely replaces it.
2.If a part of an epiphyseal plate is transplated to a
different location it continues to grow in different
location .
This indicates innate growth potential of the
cartilage.
The epiphyseal cartilages as well as nasal cartilages
showed innate growth potential but condylar
cartilage failed to show any growth.
3. Experiments on rabbits involving removal of
the nasal septal cartilage demonstrated
retarded midface development.
some argues that the surgery itself and
interferences with the blood supply to the
area , not the loss of cartilage will cause the
growth changes.
Growth of maxilla was difficult to explain as there is
no cartilage present in maxilla.
 But it was seen that naso-maxillary complex grows
as a unit and there is cartilage of nasal septum which
must be first growing and as a consequence the
entire nasomaxillary complex grows in downward
and forward direction.
Functional matrix theory:-
 Put forward in 1962 by Melvin Moss.

 It is developed from the original concept of functional

cranial component by VAN DER KLAAUW(1952).

 Neither condyle nor nasal septum is determinant of jaw

growth

 Growth of the face occurs as a response to functional

needs and is mediated by soft tissues in which jaws are
embedded.
It proposes that "the origin, development and maintenance of all
skeletal units are secondary, compensatory and mechanically obligatory
responses to temporally and operationally prior demands of related
functional matrices."

He stated that , “ bones do not grow; bones are

grown.”

According to this theory soft tissues grow and both

bone and cartilage react.
What is functional cranial
component :
Head is a composite structure

Functions such as respiration,

olfaction, chewing ,digestion,
speech etc.,

Operated in the carniofacial

region

Each function is carried by

certain tissues, spaces, &skeletal
elements- single function

Functional cranial component

 Functional cranial component

Skeletal unit Functional matrices

Periosteal Capsular
Macroskeletal Microskeletal Eg-teeth and Eg-orofacial,
muscles neurocranial
Skeletal unit :
All skeletal tissues associated with a single function
are called the Skeletal unit.
Skeletal unit comprises of bone, cartilage,&
tendinous tissues.

Microskeletal unit : made of several small

contigous units
Macroskeletal unit : when adjacent microskeletal
units work to carry out a single cranial component.
 Microskeletal units Macroskeletal units
Condylar process
Coronoid process
Angular process
Copus Mandible
Alveolar process
chin
Orbital , pneumatic,
palatal & basal micro Maxilla
skeletal units
Parietal, Temporal
,Frontal, occipetal Cranium
,synchondrosis
Functional matrix :
Consists of muscles, nerves, vessels, fat, teeth and
functioning spaces.

It is divided into the

1.Periosteal matrices
2. Capsular matrices.
Periosteal matrices :
Periosteal matrices
( Muscles ,Blood vessels, Nerves, Glands )

Acts Directly & Actively

Skeletal units

By Deposition & Resorption

Transformation in size and

shape.
Capsular matrix
Capsular matrix

Indirectly & Passively

Expansion of oro-facial
capsule

With in which facial bones

arise and grows.(translation)

• No deposition and resorption occurs

Capsular matrix :
1.Neuro – cranial capsule
2.Oro – facial capsule.

Each of the capsule is an envelop contains a series

of functional cranial components (skeletal and
functional matrix) which as a whole is sanwiched
between two covering layers.
Growth of capsular matrix is by passive
transformation of macroskeleton.
Neurocranial capsule :
Surrounds and protects
brain,leptomeninges,CSF.
Capsule is made up of skin,
connective tissue layer, aponeurotic ,
loose connective tissue, periosteum,
base of skull & 2 layers of dura
matter.
Oro-facial capsule :
Comprises spaces like oropharynx,
nasopharynx , which arises within the
facial bones , grow and are
maintained.
Skin and mucosa form the covering.

These two capsular units

expand , allowing the skeletal
units to move and translate.
Brain grows primarily and skeletal unit grows
secondarily.
Growth of cranial vault is a direct response to the
growth of the brain.

pressure excerted by the growing brain

seperates the cranial bones at the sutures.

New bone form , so that brain case fits the brain.

In the Maxilla:
The major determinant of growth in the maxilla is
the enlargement of the nasal and oral cavities,
including the sinuses which grow in response to
functional needs.
This is called the orofacial capsular matrix.
Functional matrix theory (Moss):
a. Teeth act as a functional matrix for alveolar
unit.
b. Action of temporalis muscle influences the
coronoid process.
c.Masseter and medial pterygoid muscles act
upon mandibular angle and ramus.

masseter

d. Lateral pterygoid has some influence on

condylar process.
Functioning of related tongue and perioral muscles
and expansion of the oral and pharyngeal cavities
provide stimuli for mandibular growth to reach its
full potential.
In case of hydrocephaly
Increase in the intracranial pressure

results in increase in the size of frontal and parietal

and occipital bone

results in the size of the cranuim

FMH – clinical application
RAPID PALATAL EXPANSION

Separated mid palatal suture is filled with bone as a

compensatory activity of the sutures
Slow expansion – better adaptation of muscles
FMH – clinical application
ORTHOGNATHIC SURGERIES

 Relapse after surgery--causes

 Alterations in state of equilibrium of matrix
 Failure of matrix adaptation
 Altered muscle fibre length and position

Treatment concept
Reattach muscles to specific regions rather than
permitting spontaneous reattachment
FMH – clinical application
FUNCTIONAL
APPLIANCES

Pads and shields –

stretching of periosteum
resulting in bone
remodeling .
Van limborgh’s theory :
A multifactorial theory was put forward by van
limborgh in 1970.
He explains the process of growth and development
in a veiw that combines all the three existing theories
.(genetic,sutural,cartilagenous theory)
 He suggested that six factors that control growth.
Van limborgh’s theory :
He suggested the following five factors that he believed to control growth

Intrinsic genetic ●
Genetic control
factors

Local Epigenetic ●
Genetic control originating from adjacent
Factors structures like Brain, Eyes etc.,

General ●
Genetic factors determining growth from
epigenetic factors distant structures. Ex: hormones

General Environmental ●
Non genetic factors ex: Habits , Muscle
Factors forces.

Local environmental • Non genetic influences such as nutrition,

factors oxygen.
Views expressed by van limborgh’s can be
summarized in the following six points :

1. Chondrocranial growth is controlled mainly

by intrinsic genetic factors .

2. Democranial growth is controlled by a few

intrinsic genetic factors

3. Cartilagenous parts of the skull must be

considered as growth centres.
4. Sutural growth is controlled mainly by influences
originating from the skull cartilages.

5.Periosteal growth largely depends upon growth of

adjacent structures.

6. Sutural and periosteal growth are governed by local

genetic environmental influence.
Enlow’s expanding ‘V’ principle :
Enlow 1963
Many facial bones or parts of bone have a V
shaped pattern of growth.
Growth movements and enlargement of these
bones occur towards the wide end of the ‘V’ as
a result of differential deposition and selective
resorption of bone.
Bone deposition occurs on the inner side of the
wide end of ‘V’ and bone resorption on the
outer surface.
Deposition also takes place at the ends of the
2arms of the ‘V’ resulting in growth movement
towards the ends.
Many facial and cranial bones, or parts of bones,
have a V-shaped configuration.
‘V’ pattern of growth occurs in a number of regions
such as the
 Base of the mandible
 Ends of long bones
 Mandibular body
 palate
Enlow’s counterpart principle :
Counterpart principle of craniofacial growth states
that the growth of any given facial or cranial part
relates specifically to other structural and geometric
counterparts in the face and cranium.

If each regional part and its particular counterpart

enlarge to the same extent ,balanced growth occurs.
Imbalances in the regional relationships are
produced by differences in
 Amount of growth
 Directions of growth
 Time of growth
Different parts & their counterparts are
1. Nasomaxillary complex relates to the anterior
cranial fossa
2. Horizontal dimension of the pharyngeal space
relates to the middle cranial fossa.
3. Middle cranial fossa and breadth of ramus are
counterparts.
4.Maxilla and mandibular arches
are mutual counterparts.
5.Bony maxilla and corpus of
mandible are mutual
counterparts.
6. Maxillary tuberosity and
lingual tuberosity are
counterparts.
Neurotrophic process in Oro- facial
growth
Behrents 1976
This theory states that nerve impulse has

Direct effect : nerve impulse involving axoplasmic transport has

direct growth potential

Indirect effect : on the osteogenic growth by influencing soft tissue

growth.
Different types of neurotrophic mechanisms

1. Neuroepithelial trophism
2. Neurovisceral trophism
3. Neuromuscular trophism

Neurotropism - An affinity for neural tissues

Trophism - An involuntary orienting response; positive or

negative reaction to a stimulus source
Neuroepithelial trophism

Epithelial growth is normal controlled by release of

certain neurotrophic substances by nerve synapses.
Epithelial mitosis and synthesis are neurotrophically
controlled. (THORNTON et al J Exp Zool 173:293-302, 1970)
Lack of neurotrophic process causes
 Hyperplasia
 Hypolasia
 Malformation can occur

Tissues become atrophic when de innervated.

The presence of taste buds is entirely dependent
on gustatory nerve innervation.

Some patients with facial hypoplasia or anatomic

and physiologic abnormalities of hard and soft
palate exhibit a concurrent cluster of sensory deficits,
as do many other patients with cleft palate‘.
(HOCHBERG et al J 4:47-57, 1967)
Neuromuscular trophism
At the myoblast stage of differentiation ,embryonic
myoblast establishes neural innervation without
which further myogenesis cannot continue.
Neurovisceral trophism
Periosteal matrices genetically determine the
apparent localized neurotrophically controlled
genomes.
Ex: salivary glands , Fat tissue regulate the
embedded passive position of the skeletal units.
Adipose tissue is definitely affected by neural
control,in terms of metabolism, histologic
type,composition, and maintenance.
It has been shown that unilateral cervical sympathectomy
produces an ipsilateral atrophy of cheek fat.

Increases and decreases of mature salivary gland weights

and changes in constituents that are influenced
differentially by sympathetic and parasympathetic
innervation. HAUSBERGER et al
Servosystem Theory of Craniofacial
Growth
Alexandre Petrovic 1974
Petrovic’s research came to focus on the nature of
cartilage growth in the craniofacial complex, and
especially of the growth of the secondary cartilage of
the mandibular condyle.
He and his colleagues also demonstrated that the
growth of the primary cartilages of the craniofacial
complex, such as the cranial base and nasal septum,
was influenced significantly less by local epigenetic
factors
The servosystem theory relies on the vocabulary of
cybernetics to describe the growth of the craniofacial
complex.
Two principal factors:
1) Hormone and genetic factor driving growth of midface
and anterior cranial base, and in turns
(2) the growth of midface affects the growth of mandible.
Servosystem Theory
First, as the midface grows downward and forward
under the primary influence of the cartilaginous cranial
base and nasal septum,influenced principally by the
intrinsic cell-tissue related properties common to all
primary cartilages and mediated by the endocrine
system.
 the maxillary dental arch is carried into a slightly more
anterior position. This causes a minute discrepancy
between the upper and lower dental arches, which
Petrovic referred to as the “comparator,” that is, the
constantly changing reference point between the
positions of the upper and lower jaws.
Second, proprioceptors within the periodontal
regions and temporomandibular joint perceive even
a very small occlusal discrepancy and tonically
activate the muscles responsible for mandibular
protrusion.
Third, activation of jaw protruding muscles acts
directly on the cartilage of the mandibular condyle
and indirectly through the vascular supply to the
temporomandibular joint, stimulating the condyle to
grow.
Finally, the effect of the muscle function and
responsiveness of the condylar cartilage is
influenced both directly and indirectly by hormonal
factors acting principally on the condylar cartilage
and on the musculature.
Conclusion :
Various theories as put forward to explain the
growth of face,which helpful in knowing about the
anatomy and when ,where growth occurs which
helpful in planning various treatment modalities
that can regulate growing dentition and jaw bones.
References :
Contemporary orthodontics ,fourth edition,
WILLIAM.R.PROFIT.
Dentofacial Orthopedics With Functional Appliances ,
2ND Edition , GRABER,RAKOSI, PETROVIC.
Textbook of orthodontics,1st edition ,S.GOWRI SANKER.
Theories of Craniofacial Growth in the Postgenomic Era
David S. Carlson,Semin Orthod 11:172–183 © 2005
Elsevier
Neurotrophic Processes in Orofacial Growth
MELVIN L. MOSS, J DENT RES 1971 50: 1492