Growth at facial sutures

CROWTlI

AT FACIAli

SITTURES

INTRODUCTIOS

present time much work is being A T andTHE:patterns of growth in the human

carried out on the methods, sites, face.l+ j This knowledge is of fundamental importance in the understanding of the etiology of malocclusions and facial deformities. Certain conclusions, however, are of doubtful validity. as they appear to bc based on an inadequate study of the mrthods of suture growth and the precise arrangements of the sutures in the facial skeleton. It, is the purpose of this article to investigate and discuss these matters. GROM’TH

AT

SUTURES

The structure of growing and adult sutures has been described by Pritchard and his associates.” They have shown that a typical facial suture (Fig. 1) is composed of five layers of tissue between the bony margins of the sut)urc. These la.yrrs arc : .I. A cellular layer belonging to each bony unit. 2. A fibrous le,ycr continuous with the fibrous p,eriostrum covering each bone. 3. L4 central layer, containing blood vrsscls and unitiIkg strands of collagcnous fibers. Growth at a suture takes place at. each of the cc>llular (cambial) layers and may differ in its intensity and amount for each of the bones. The relationship of the bones to one another, at a suture may be (1) an edge-to-edge relationship (Fig. 2) or (2) an overlapping relationship (Pig. 3). If the relationship is of the edge-to-edge variety, growth at t,hc sut,ure is correlated with separation of the bony elements. Growth may take pla.cc at t,he sutural surface of one or the other of the bones or at both. The process may or may not involve a change in position of the suture (Fig. 2). Tt is important, moreover, to know whether or not. the suture changes position, as WI’tain sutures or points on sutures arc often taken as “fixed points” in superimposing ccphalograms in serial studirs of facial growth. Tf, howevrr, the rclat,ionship is of thr overlapping variety, growth at, the suture ncc~l not involve scparat,ion of the bones. With surface deposition, one boric migtxtrs over the surfacc~ of t,hc other and the position of the snt,urc From

the

Anatomy

Deuarhnent,

Queen’s

University. 381

.I.

II.

s~:o’I”I’

3 ---1 DD A, 0.

c.

D.

E.

shows new bone (lcpoaition. Wig. Z.--C:rowth at an cdgc:.to-mlge suture :
q------w-w-

-

1

Q

b

Fig. S.--Growth at an overlapping suture. Wit11 cleposition of bone on not in the suture. one bone migrates upward over the surface of the other position of the suture is altcred. 1. (kipinul position : 3. na9v Ilosition.

the and

surface. but thr, suvfacr

C:lW\\;th at SntUrYS does llot in itsdf produce sep:Wation of t,he bones at This is brought, about by the growth of other organs snc>h as t,hc (*;\rtilagc ot‘ the chondrocr~anial and chontlrofacial skclcton, the l,rain, the cyclmlls, and t,hc tongues

tt1v

sntuw.

The snturcs of the craniofacial skeleton can hc grouped into a numhcr of systms. The sntnpcs making ~1) each syst,elll are SO arranged ibs to pclrnrit growth in a certain direction. ‘l’hc suture systems in t,he human fac:cs sntut~c

2l.W :

1. The sagittal sutu~ system, made up of the mid-palatal, intermaxillary, internasal, and metopic sutures with the mandibular symphysis. It is co111l)lc~tc in f’ctal lift and at birth, and permits growth in width of the facial skclcton. At the end of the first year. the tnandibular symphysis and the metopic~ srIt,ut*chin the ma,jority of persons have united. and the sagitt,al sutnrc systelrl is no longer complctc. It is donhtfnl whcthcr :rny further growth takes place in the mitl-palatal suture after this time. By the end of the first, yea I*, the distitllcc l)vtwcvn the Iwo orbital caritics across t,hc bridge of th(h K~OSC has ~a~hc~l nctnlt tlimcnsions in nmny children.

Fig. 4.--Uiagram to show the position of the maxillary and craniofacial suture Sotr relationships of frontomaxillary to the frontonssal suture and of the posterior N, Nasai bone : E, ethmoid of the maxilla to the palatine bone and pterygoid plates. process of maxilla. Illate) ; N, sphenoid (including pterynoid plates) ; Z, zygomatic

systems. border (orbita

2. !Z’he mazillar~ slstuye system, macle up of the sutnrrs separating the t~~;lxiIla from the nasal, frontal, lacrimal, facial cthmoitl, palatine, zygomat’ica, ant1 ~~omcr bones (Fig. 4). This system consists of two limbs, a horizontal ]ilrlb at the medial and lateral walls of the orbital cavity (including the votrrerine-maxillary junction of the nasal septum), and a vertical limb in the ptcrygopalatine fossa (hetwcen t,he maxillary and palatine bones). and 3. The cmn.iofacial s&we s@em, made up of the supramaxilla.ry 18~1 ro~naxillary facial bonc~s on one side (nasal, lacrimal, facial et,hmoid, pa1;1-

Of llll,

ItlilXillit.

Fig. 5.-Diagmrn to show the position of the zygornatic the maxilla BS seen in a transverse section. Arrow indiratrs the direction of growth of the maxilla in early childhood. Plate) ; Pt., pterygoid lrlates : %u~I.. zyaornatic bone.

and palatine bones retativc to position of nasal septum and Pal., L’alatinc bone (vertical

b’ig. 5 shows in ii tlina.t’;ttttttt;tt,iC ntantt(‘t’ the relationship of the palatine :lntl zygotnatic bones to the tnasilln its SCW~itt a horizontal (transvcrsc) stdion of the t&c. .It will 1,~ SPOIL that the v~rtid plittc of the palatine l.)on(~,which fot’tlts part of th(a sick wall of the nas;tl cavity, OY(~~IRPS the back part of the nasal SLU+‘:MZ of the ttlitdll:t. ‘I’hc two overlapping l~oncs bctwecrt them form t,ho boundaries of the grciltct’ palatine canal I(1ittlitlg frortl the l,tct.ygop,?Intillc fossa above to the greater palntinc foramcn on the palate bc~low. The zypotnatic hone nrt~iculatzs with the snrfacc~ of’ the zygomatic princess of the mnsilln which facts natww.rd and slightly forwit rd.

Fig.

R.-W’ontonasal Note

the

and frontonmxillary higher position

of

sutures in a the frontonasal

child

of suture

6 years in the

and adult.

in

an

aclult.

/‘t’OtltOlttil~illi~~~ Slltllrt’. ‘I’h(s sutl~t*~~Itct\v(~(~ll the ttasitl ittttl f’t*otttill I)OI~CS is 011 the ft*otttitl It(ttl(J with ;lg~. 01’ thcl ctvc~rlapping nt riety antI ItilSiOtl :ISWII~~S This cillt lte sho~~t ils ~OIIOWS :

tll(’

I. Nasion is usl~itlly closcbt* to thtx llppct* ot*bit;~l tttitt’gitl itI ttdlllt, ~l
Sertions, the direction oi the frontortasal sutllW ~~]~\\ritt’(IillIt OUt\V;llYl for SOlllC cliStilll(~(! hein tllc, iltllllt is llSll;lll~ SOIIIC foty it ~.lltms fot*w;t rtl. N;lSiOll t]ist,;l.tl(~c~ ;ll)o\(~ thtl Icv(~I of thta rtlt)f OC the lla~al cavity In cahil(lt*cn it, is at almut the siltttt: (etil)riEortt1 plntc). lovcl (Fig. 7). is

Sppn

to

1’1111

Therefore, the position of nasion cannot be taken as evidcncc of separation of the maxillary and frontal bones and it must be used with care as a “fixed” point in the superimposition of serial ccphalograms. Investigators sometimes treat changes at the posterior surface of t,hc maxilla as seen in lateral cephalograms as evidence of sutural growth. Diatnond4 pointed out that the posterior surface of the maxilla grows into the pt,erygopalatine fossa throughout childhood and adolescence and does not become buttressed against the pterygoid processes until adulthood. Furthcrmore, the alveolar bulb of the maxilla projects backward on the outer side 01 the lateral pterygoid plate and undergoes a p~~ccss of altc~rnating cxpatlsinn and contraction as the molar t&h develop within it and move forwaI,tl into

B’ig. ‘I.--Diagram of a sagittal section through the upward migration of nasion relative to the roof frontal bone; E’, ethmoid ; Na, nasion.

occlusion.7 necessarily sutures.

the front of the nasal of the nasal cavity. N,

cavity Nasal

to sho\r bone; F.

Therefore, growth at the posterior border of the maxilla dock not involve growth at the deeper palatomasillary or palat,opt,erypoid

Each suture has two growth sites, one for each of the bony elements. Growth at a suture may or may not involve a change in position of the suture and may or may not involve separation of the bones. During early childhood the maxilla is thrust downward and forward from the anterior segment. of the cranial base, but this process of bodily moremcnt of the boric is not brought about by growth in the sutures. The separating force is provided by growth of the septal cartilage and the orbital contents. The position of nasion and the posterior border of the maxilla, as seen in lateral cephalograms, cannot be used as direct evidence of sut,ure growth with scpn.t*ntion of t,hr bones in the analysis of growth chnngcs in the maxilla. REFERENCES 1. Hjiirk,

A.: odontol.

Facial Growth in Man Studiell scandinav. 13: Y-31, 1955.

With

the

Aid

of

Metallic

Implants,

Acts,

Additional

Reference

List

The following references should be atNed to the ;Lrticlr entitlrtl “Care ol‘ the Deciduous Teeth as t,he Basis of Occlusion of the Permanent Dentition” by l~curnan 11. Laugh (AK J. ORTHODONTICS 41: 90-106, February, 1955) : Rogers, Rogers, Rogws, Rogers, ,\lershon, hlrr~hon, .\lershon, ,\Iershon,

,Ylf red P. : Exercises for the Development of the llluscles of the Face, With a Viclw Dental Cosmos 60: 857-876, 191N. to Increasing Their Functional Activity, Increased Function in Treatment of Dental Anomalies, INT. .J. OWIIOAlfred P.: IKlNl'IA 15: 731-742, 1929. Alfrerl P. : The Place of Myofunctional Treatnwnt in the Correction of Itlalowlusion, CT. Am. Dent. A. 23: 66-78, 1Y:IR. Evolution, I)evelopment, ant1 Application of Rlyofunctional Thrrap!~ Alfred P.: in Orthodontics, Am. .T. Orthoilontics and Oral Surg. 23: 462-481, 1937. Facial Changes, Symposium, Dental (‘osmos 77: 1068-1079, 19%. .lohn V.: Why the Lingual Arch Is Applicable to the Orthodontic I’rol~le~n, n. .Tohn V.: Record 46: 297, 192fi. The Removal-)le Lingual Arch Appliance, IiYT. J. ~RTHOlltlK’l’IA 12: Sohn V.: 1002-1026, 1926. Failures, TKT. .J. OI<~aOI>OIGl’Iz\ 22: 338-343, 1936. John V.: