The Effects of Disturbed Nutrition on Dentofacial Structures

Dento-facial deformity requiring mechanical reconstruction is becoming an ever increasing problem. The forces involved in development of facial alignment are active from conception to death. Of these forces, some may be active for short intervals of time during critical developmental periods. They may leave their imprint on future growth development or degeneration. Other factors may be active over more prolonged periods or even over the entire span of life. The summation of these forces like the solution of a complex mathematical formula is the facial development at a given time.

Disturbed nutrition may exert a profound effect on the developing dento-facial structure. Through heredity, racial patterns, psychological maladjustment of mother and infant, position of the foetus in utero may all influence the growth of a child. Nonetheless, even with these factors at play, the adequacy of nourishment is primarily effected and in turn imposed on the developing individual. 

Figure 1. 124-B. Cast of teeth of child (male) of good development at age 2. Note symmetry of arch and spacing of teeth. Between age 2 and age 3 child developed habit of poking objects up right nostril, had a chronic infection in right nasal cavity. Note loss of symmetry, flattening of right atch, shortening of linear distance from medial border of right central to distal border of right first molar, when compared to left. Note lessened distance from right molar to median raphe.

 

With our increased recognition of prenatal injury, both by disease and disturbed nutrition, at critical development periods, producing many deformities, such as congenital heart disease,¹ blindness, disturbed dentition, cleft palate, absents, or disturbance in development of other organs,² is it illogical to assume that similar factors, though less intense, may create lesser deformities? The period when congenital failures in heart disease occur has been fairly well established by embryologists. The period when German measles produce blindness in the foetus is rather critical and of short duration,³ usually within the first two months of pregnancy.

It is my purpose to discuss the possible effect of disturbed metabolism of the mother during the time she is carrying the infant, and to suggest that critical periods exist in the growing embryo when an illness, accident or imposed malnutrition, or changes in environment or mode of living of the mother may effect the development of the foetus. Reference will also be made to the postnatal factors which influence the development of the dental structures. Those which have received wide acceptance have been the sleeping habits of the infant, also such habits as sucking the fingers, pressure phenomena, injuries at birth, or any other traumatic factor which would interfere with the growth of the oral structures; infections of the paranasal sinuses (Fig. 1 and Fig. 2) or in the oral cavity. Whether or not the infant is nursed has been reported by us to exert a marked effect on the development of the malar prominence, and in turn, the dental arches.⁴

The adequacy of the dietary, particularly in the early period of life, is very important. Metabolic upsets, whether due to illness, changes in food and water supply, or dietary inadequacies, play an important part in determining the adequacy of the facial development. McMurrich,⁵ Arey,⁶ and Gray,⁷ state that the mandibular arch in the foetus begins to develop about the 28th day while the dental ridge begins to develop someplace between the 40th and 45th day. The ten special dental germs of the deciduous teeth begin to take shape by the time the embryo is sixty-three days of age. It is understandable that metabolic disturbances of the mother during this period may affect the adequacy of the oral structures of the infant. Calcification of the enamel organ begins to develop at the fifth month. Serious illness of the mother from this time on may be recorded as ridges in the enamel of the tooth when it is finally erupted. The first permanent molar bud is formed by the 120h day, and becomes subject to metabolic insult.

Figure 2. #SP. (30B, 31B, 32B) Male. X-ray of base of skull of child shown in Fig. 1 at 17 years. Note deformity of arch symmetry produced during third year of life persists. Has missing upper right 3rd molar. Other 3rd molars present.

Fig. 3. #3519 Male, age 7½ years. Marked faure in development of arches, sphenoid sinus, bridged pituitary fossa and failure of development of frontal sinus. Mother ill during entire pregnancy.

In a series of fifteen children with very small deciduous teeth with narrow arches, a history of serious metabolic (Fig. 3) or psychologic (Fig. 4) disturbance in the first three months of pregnancy was given. This does not infer that all illnesses during the early months of pregnancy will result in the problem of small deciduous teeth, or dental arches.

Fig. 4. #123-B Female. Moderate crowding of teeth in child, age 7. There is both delay in dentition and crowding of deciduous teeth in mandible. Lower permanent centrals are lingual to the line of occlusion. Mother was under extreme tension during entire pregnancy.

Fig. 5. #6330 Eleven days old female infant. Receding mandible. Mother suffered extreme anemia and very ill throughout pregnancy.

 

The receding mandible (Fig. 5) or the failure in the development of the maxillary portion of the face may be present at birth, as may the protruding mandible (Fig. 6). Serious nutritional disturbances of the mothers of these children about the seventh week of pregnancy was demonstrated.

Brash,⁸ Nance,⁹ Baume,¹⁰ and others have pointed out that the development of the anterior portion of the mouth is determined before the child is one year of age. It is, therefore, of utmost importance that the infant be sheltered from metabolic insults, and that every encouragement for breast feeding should be made.

After the infant is born, metabolic insults which he suffers leave their mark in the bones that are developing under stress.¹¹The lines of arrested growth seen in the long bones serve as a nutritional history of the growing child. These lines indicate the period of arrested development during which an insult occurred,and remain throughout life. In a similar manner, transverse ridges on the teeth indicate the developmental period when nutrition of the growing child was altered. The teeth can be used as accurate historians up to the 7th year, when the crown of the second permanent molar is completed. For instance, a child who had developed without serious illness (Fig. 7) until the age of 1½ years, contracted measles. At this time, the epiphysis of the metatarsal of the great toe was forming, and showed X-ray evidence of fragmentation (Fig. 8) due to the measles. The distal epiphysis of the femur which is normally present from birth, also showed evidence of fragmentation at its margins. A large scoring was produced in the growing tibia and femur which are clearly visible in illustration, Fig. 9. The epiphysis of the femur healed as the child recovered from the measles, but left a scar on the developing bone (Fig. 10). Since the basal epiphysis of the great toe did not complete its development until three years and eleven months, the fragmentation caused by the measles healed only as that epiphysis completed its development (Fig. 11).

Figure 6. #4272 (30). Skull of female infant, age 6 weeks, showing protrusion of mandible. Mother had severe anemia and pernicious vomiting first months.

 

Another boy, born of a mother who suffered from profound anemia during her pregnancy and who was unable to nurse the child, had much difficulty in becoming established on an agreeable nutritional program. He developed chronic bronchitis and asthma by the age of three months, which caused marked disturbance in his osseous development (Fig. 12). The bones of his feet were particularly affected.^{12, 13} Healing of the basal epiphysis was not complete at 3 years 10 months and required another year for the epiphysis to appear “normal” (Fig. 13). The X-ray plainly shows the scarring fourteen years later. In contrast to the first boy who has become an athlete, the second boy has flat feet and shuns physical exercise.

Figure 7 #2420 Male. Foot of child of 1 year 4 months showing regular development.

Fig. 8. #42420 (79) Male Foot of child age 2 years. Note fragmentation in proximal epiphysis of great toe.

Figure 9. #2420 (80). Male, age 2 years. X-ray of knee showing heavy score in femur and tibia, also fragmentation of lateral margin of epiphysis of femur due to measles at the age of one and a half years.

Fig. 10. #2420 (86) Male. age 3 years, 5 months. Proximal epiphysis still separated.

 

The fact that the anterior portion of the face is in part controlled by adequate dietary can be illustrated by two sisters (Fig. 14 and Fig. 15). The older child has a narrow and poorly developed face. Since both the father and mother have narrow faces and crowded teeth, one is at first inclined to believe that heredity has determined the structures of the child’s development. She had very small primary dentition, and the lack of development of the mandible and maxilla is also reflected in the paranasal sinuses and all structures beneath the base of the brain. This child was carried during the time the mother was under extreme emotion tension and accompanying malnutrition. The second child was born after the mother had been living on a better nutritional program and was in relatively good physical and emotional health throughout her pregnancy. As an infant, this child was maintained on a nutritional program superior to that of her sister. She did not suffer from the recurrent metabolic upsets during her first year of life which had plagued the older child.

Fig. 11. # 2420 (88) Male, age 3 years, 11 months. Epiphysis healed but shows scar. 

 

From the basal view, it is particularly evidenced that the second girl has developed a regular mandible with adequate room in the anterior portion of the mouth for all of her teeth, and that her mandible is materially larger than that of her sister who is two years older. Likewise, the length is greater and thickness of the tami of the mandible are materially heavier, as are her coronoid processes, which shows that the muscular development is superior to that of her sister. The younger child shows a remarkable breadth of the oral structures and symmetry of the face, in contrast to the older child whose nares are pinched and the nasal passageways are so small that the tonsils and adenoids have been a problem.

 

 

Fig. 12. #4164 (3) Male, age 2 years, 10 months. Child suffered many recurrent metabolic upsets in form of asthmatic attacks. Note fragmentation of proximal epiphysis of hallux and bases of the metatarsal bones.

 

In a trio of rural sisters of superior physical development (Fig. 16, 17 & 18), the mother enjoyed good health throughout her pregnancies and nursed all three for nine months. Two of the children, the oldest and youngest, developed normal facial structures, while the second shows a moderate distortion of the face. When this child was but a few days of age, her mother suffered from a severe respiratory infection, a fact which may be suspected of causing the deformity in the child. She did not discontinue nursing in spite of the fact her flow of milk diminished and the child was also ill. It is obvious from the posteroanterior view that her incisor teeth are crowded while in the sisters, adequate room exists. When age is considered, the lateral view shows slightly less development of nasal cavity in the second. The basal skull view shows greater symmetry of structures in the second child. Likewise, her arches are narrower in the area of the second deciduous molars than either of her sisters.

Fig. 13 #4164 (11) Male, age 3 years, 10 months. Note progressive healing of proximal epiphysis of hallux.

Figure 14. 12889-F (24,25,26B). Age 8 years.

Figure 15. 13139-F (21,22,23B). Age 6 years. Sister to #12889 (Fig. 14). Elder sister born when mother was on poor nutritional program. Younger born during improved circumstances and better infant nutrition. In postero-anterior view, note greater breadth between second molars and space between incisors in younger child. In lateral view, younger child has heavier mandible and more adequate nasal area. Note small mandible and protruding upper teeth and narrow arches when compared with full arch of younger sister.

Figure 16. #14825, (6,7,8B). Younger sister, age 3 years.

Figure 17. #14827-F (9,10,11B). Second sister, age 7 years. Note lesser width of arch in area of second deciduous molar than in sister, age 3 years.

Figure 18. #14828 (12,13,14B). Older sister, age 9 years.

 

CONCLUSION

The adequacy of dento-facial structures are influenced by nutritional factors both prenatal and postnatal.

 

References Cited:

1. Abbott, Maude E., Congenital Heart disease, Nelson Loose Leaf Living Medicine, Vol. IV, pp. 120-17, 1951
2.  Gregg, N. M., Congenial Cataract Following German Measles in Mother, Transactions Ophthalmology Society of Australia (1941), Vol. 3, pp. 35-46, 1942.
3. Swan, C. and others, Congenital Defects in Infants Following Infectious Diseases During Pregnancies with Special Reference to the Relationship Between German Measles and Cataract, Deaf-murism, Heart Disease, Microcephaly, and Other Anomalies, Med Journal of Australia, 1943, Vol. 2, pp. 201­-220, Sept. 14, 1943.
4. Pottenger, F. M., Jr, and Krohn, B., The Influence of Nursing on Facial Development, Arch Ped., 67:454, 1950.
5. McMurrich, J. P., The Development of the Human Body, P. Blakiston’s Son & Co., 1923.
6. Arev, L. B., Developmental Anatomy, W.B. Sanders Co., 1925.
7. Gray, H., Anatomy of the Human Body, 25 edt, Lea & Febiger, 1948
8. Brash, J. C., The Growth of the Jaws, Normal and Abnormal, in Health and Disease, Dental Board of the United Kingdom, 30-31, 1924
9. Nance, H. N., The Limitations of Orthodontic Treatment, Part I, Am. J. Orthodontist and Oral Surg., Vol. 33, No. 4, 177-223, 1947.
10. Baume, L. J., Physiological Tooth Migration and Its Significance for the Development of Occlusion, Part I, J. Dental Research, Vol. 29, No. 2, 123-132, 1950.
11. Pottenger, F. M., Jr., Studies of Fragmentation of the Tarsal and Metatarsal Bones Resulting from Recurrent Metabolic Insults, Trans. Am. Ther. Soc., Vol. 45, 1945.
12. Sontag. L. W., and Harris, L. M., Am J. Diseases Children, 56, 1248, 1938.
13. Francis, C. C., Am. J Diseases Children, 57-817, 1939.