03 growth of maxilla

PRESENTED BY
DR.PRIYANKA K BIND
FIRST YEAR PG STUDENT
DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL
ORTHOPAEDICS
GROWTH OF MAXILLA

CONTENTS
 Prenatal embryology of maxilla
 Development of palate
 Postnatal growth of nasomaxillary complex
 Developmental anomalies involving maxilla

GROWTH
PRENATAL
PERIOD OF
OVUM
PERIOD OF
EMBRYO
POSTNATAL
PERIOD OF
FETUS

PERIOD OF OVUM: Extends for a period of approximately
two weeks from the time of fertilization. During this
period the cleavage of ovum and the attachment of the
ovum to the intra-uterine wall occurs.
PERIOD OF EMBRYO: Extends from the 14th day to the 56th
day of intrauterine life. During this period the major
part of the development of the facial and the cranial
region occurs.
PERIOD OF THE FETUS: Extends between the 56th day of the
intrauterine life till birth. In this period, accelerated
growth of the craniofacial structures occurs resulting in
an increase in their size. In addition, a change in
proportion between the various structures also occurs.

MAXILLA
 The midface, or nasomaxillary complex, is composed
of the paired maxillae, nasal bones, zygomatic
bones, lacrimal bones, palatine bones, and, within
the nasal cavity, the turbinates and vomer.
 The midface is connected to the neurocranium by a
circummaxillary suture system and, toward the
midline, by the cartilaginous nasal capsule, nasal
septum, and vomer.
Orthodontics current Principles and Techniques by Graber,
Vanarsdall, Vig, Fifth Edition

 There is also an intermaxillary suture system
composed of the midpalatal, transpalatal,
intermaxillary, and internasal sutures. With the
exception of the inferior turbinates, all the bones
composing the midface are formed
intramembranously from a connective tissue
mass.
Orthodontics current Principles and Techniques by Graber,
Vanarsdall, Vig, Fifth Edition

ANATOMY OF MAXILLA
Orthodontics current Principles and Techniques by Graber, Vanarsdall, Vig, Fifth Edition

PRENATAL EMBROYOLOGY OF MAXILLA
 Facial development results mainly from enlargement
and movement of the frontonasal prominence and
four prominences from pharyngeal arch I, the paired
maxillary prominences, and mandibular
prominences. These structures surround the
stomodeum.
 The maxillary and mandibular prominences develop
as a result of neural crest cells migrating and
proliferating into pharyngeal arch I.
Textbook of Orthodontics, Samir E. Bishra

 Prenatal development of the maxilla begins in
the 4th week of intrauterine life.
 During this period, there is
1. Migration of neural crest cells
2. Formation of branchial arches
Textbook of Orthodontics, Samir E. Bishra

 At the 4th week of IUL, a
prominent bulge appears
on the ventral aspect of
the embryo, representing
the developing brain.
 Below the buldge a
shallow depression,
known as the
stomatodeum, which is
the future ORAL CAVITY.
 Buccopharyngeal
membrane lines the floor
of the stomatodeum.
Textbook of craniofacial growth, Sridhar Premkumar

There are series of mesodermal thickenings in the wall of the
cranial most part of the foregut. These thickenings are known as
Pharyngeal Arches of Branchial Arches
The pharyngeal arch apparatus (lateral view of the external surface of the
embryo) during the fourth week. Four pairs of pharyngeal arches are evident.
The fourth arch is the result of fusion of arches IV and VI. Arch V regresses
and does not give rise to structures in adults. Textbook of Orthodontics, Samir E.
Bishara

The pharyngeal arch apparatus, a viewed along the plane of section. The
pharyngeal arch apparatus gives rise to important head and neck structures.
The pharyngeal arches are partially separated on the external surface by
fissures called grooves, or clefts, and on the internal surface by pouches. The
arches have a core of mesenchyme, an external surface of ectoderm, and an
internal surface of endoderm. The arches have specific nerves, cartilages,
muscles, and arteries associated with them. Textbook of Orthodontics, Samir E.
Bishara

Textbook of Orthodontics, Samir E. Bishara

 The first branchial arch is
called the mandibular arch
and plays an important role
in the development of the
naso maxillary region.
 Mesoderm covering the
developing forebrain
proliferates, and forms
downward projection that
overlaps the upper part of
the stomatodeum this
downward projection is
called the frontonasal
process
 The stomodeum is
overlapped superiorly by
frontonasal process &
laterally by mandibular
arches of both sides

FORMATION OF MAXILLARY AND
MANDIBULAR PROCESS
 Mandibular arch forms
the lateral wall of the
stomatodeum
 This gives off the bud
from its dorsal end – the
maxillary process and
grows venteromedially –
mandibular process

 One of the first events in
formation of facial
structures is fusion of the
medial ends of the
mandibular prominences
in the midline to form the
chin and lower lip. In the
inferior and lateral
portion of the frontonasal
prominence, bilateral
localized areas of surface
ectoderm thicken to form
nasal placodes .

 The center of the placode
becomes thinner,
eventually leading to loss of
ectoderm and formation of
nasal pits. The nasal pits are
the precursors of the
nostrils and nasal cavities.
 The mesenchyme along the
periphery of the nasal
placodes proliferates and
form horseshoe shaped
ridges called the medial
nasal prominences and
lateral nasal prominences .

 The result is that the
due to proliferation of
mesenchymal tissues
of maxillary
prominences, they
become larger and
move medially and
fuses first with the
lateral nasal
prominence and then
with the median nasal
prominence.
 Medial and lateral
nasal prominence also
fuses with each other
resulting in formation
of external nares

FORMATION OF NOSE
 Receives contribution from the frontonasal process
and the medial and lateral nasal processes of the
right and left sides.
 Gradual narrowing of the frontonasal process results
in approaching of external nares towards each other.
 The deeper part of this frontonasal process forms the
nasal septum .
 As the nose becomes prominent, the external nares
come to open downwards instead of forwards.
Orthodontics diagnosis and management of Malocclusion &
dentofacial deformities – O P Kharbanda, 2 edition

FORMATION OF NASOLACRIMAL DUCT
 It is seen that the maxillary process fuses
with the lateral nasal process
 However, this fusion not only occurs in
the region of lip but also extends from
the stomatodeum to the medial angle of
the developing eye.
 This line of fusion marked by a groove
called the naso-optic furrow or the
nasolacrimal sulcus.
 A strip of ectoderm is buried along the
furrow and this gives rise to nasolacrimal
duct.
Textbook of craniofacial growth, Sridhar
Premkumar

 The medial nasal
prominences move toward
each other, fuse in the
midline, and form the
intermaxillary segment.
 The intermaxillary segment
is of special importance
because it gives rise to the
philtrum (middle portion) of
the upper lip , four incisor
teeth, alveolar bone and
gingiva surrounding them,
and primary palate

Approximately 10 weeks. The entire upper lip is derived from the
fused medial nasal prominences and maxillary prominences. The
midline of the nose comes from the medial nasal prominence,
whereas the ala of the nose is derived from the lateral nasal
prominence. Textbook of Orthodontics, Samir E. Bishara

OSSIFICATION OF MAXILLA
 Ossification of the maxilla begins around the 7th week of
intrauterine life.
 Intramembraneous type
 The primary centre for the ossification appears in the angle
between the division of a nerve i.e. Where the
anterosuperior dental nerve is given off from the inferior
branch of infra orbital nerve, above the part of the dental
lamina from which develop the enamel region of the
canine.

 From this centre, the bone spreads:
1. Posteriorly: below the orbit towards the
developing zygoma
2. Anteriorly : towards the future incisor
region
3. Superiorly: to form the frontal process

 Secondary ossification centres for maxilla are
zygomatic, orbitonasal, nasopalatine and
intermaxillary which gets initiated at around 8th
week of IUL
 At the 8th week of IUL, intramembraneous
ossification centres for the following appear:
 Nasal and lacrimal bones
 Medial plates of sphenoid
 Vomer
 Zygomatic bone
Premkumar

GROWTH AND DEVELOPMENT
OF PALATE

STRUCTURE
OF PALATE
PRIMARY
PALATE
SECONDARY
PALATE

The palate begins to develop early in week 6, but the
process is not completed until week 12.
The most critical period during palatal development
is the end of the sixth week to the beginning of the
ninth week
PRENATAL GROWTH AND DEVELOPMENT OF PALATE
FORMATION OF
PRIMARY AND
SECONDARY PALATE
ELEVATION OF
PALATAL SHELVES
FUSION OF PALATAL
SHELVES
Premkumar

• The entire palate develops from two
structures the primary palate (premaxilla)
and the secondary palate.

 The primary palate is the
triangular-shaped part of the
palate anterior to the incisive
foramen. The origin of the
primary palate is the deep
portion of the intermaxillary
segment, which arises from
the fusion of the two medial
nasal prominences.
 The secondary palate gives
rise to the hard and soft
palate posterior to the
incisive foramen. The
secondary palate arises from
paired lateral palatine shelves
of the maxilla. Textbook of Orthodontics, Samir E. Bishara

These shelves are comprised initially of mesenchymal
connective tissue and are oriented in a superior-
inferior plane with the tongue interposed.

 Later, the lateral palatine shelves become elongated and the
tongue becomes relatively smaller and moves inferiorly at
around 7th week. This allows the shelves to become oriented
horizontally, to approach one another, and to fuse in the
midline

The median palatine raphe is a clinical remnant of fusion
between the palatine shelves, and the incisive foramen is
present at the junction of the primary palate and the lateral
palatine shelves.
 The lateral palatine shelves
also fuse with the primary
palate and the nasal
septum. Fusion between
the nasal septum and
palatine processes proceeds
in an anteroposterior
direction beginning in the
ninth week .

OSSIFICATION OF PALATE
 The site of fusion is the future midpalatal suture.
 Ossification starts by 8th week of IUL.
 There is only one center of ossification for each maxilla.
Posterior part of the palate receives ossification center
from the palatine bone. Posterior most part remains
unossified as soft palate and uvula. Initially, the palatal
arch is very shallow, the depth is gained postnatally.

 The premaxillary/maxillary suture closes at
approximately 3 to 5 years of age 6.
 The midpalatal and transpalatal maxillary sutures,
which are the major intermaxillary growth sites
associated with transverse and anteroposterior
maxillary growth, have been reported to close between
15 and 18 years of age and 20 to 25 years of age.
 Closure of the circummaxillary sutures occurs somewhat
later than closure of the intermaxillary sutures.

POSTNATAL GROWTH OF
NASOMAXILLARY COMPLEX

 The two maxillae articulate with each other in the
midline at the intermaxillary suture. The maxillae are
attached to other bones by a complex sutural system.
 The position of the maxilla is dependent on the growth
at the spheno-occipital and sphenoethmoidal
synchondroses.

 Age of approximately 7 years is something of a
benchmark for growth of the midface.
 Growth of the central nervous system—the brain and
eyes—is essentially complete at about 7 years of age.
Concomitantly, the cartilage of the sphenoethmoidal
synchondrosis ossifies and a suture is formed
between the sphenoid and ethmoid bones at about
that time. As a result, a relatively stable anterior
cranial base is established extending from sella
turcica to the foramen cecum.

 Also the growth of the cartilages of the nasal
capsule and nasal septum changes significantly.
 The cartilaginous nasal capsule becomes ossified
and the nasal septum, which remains
cartilaginous throughout life in humans,
decreases significantly in growth activity.

 The growth of nasomaxillary complex
is produced by the following
mechanisms:
1. Displacement
2. Growth at sutures
3. Surface remodelling

SECONDARY DISPLACEMENT
Structures of the nasomaxillary complex are displaced forward as the
cranial base lengthens and the anterior lobes of the brain grow in size.

 Primary displacement can be
explained by 3 theories
1. Sutural theory
2. Cartilaginious theory
3. Functional matrix theory

SUTURAL THEORY BY SICHER
 Maxilla is attached to the cranium by frontomaxillary,
zygomaticomaxillary, zygomaticotemporal, and
ptergopalatine suture, which are more or less oblique
and parallel to each other.
 Thus growth in these areas will push the maxilla
downward and forward.
 But
1. Suture is a tension adapted tissue
2. Suture doesnt grow when transplanted

Sutures are oblique and parallel to each other. This allows the downward and forward
repositioning of maxilla as growth occurs at these sutures.
As growth of surrounding soft tissues occurs, the maxilla is carried downwards and
forward. This leads to opening up of space at the sutural attachments. New bone is
formed on either side of the suture. Thus overall size of the bones on either side
increases. Hence a tension related bone formation occurs at sutures.

CARTILAGINIOUS THEORY
 Cartilaginous parts of the skull must be recognized as
primary centers of growth, with the nasal septum
being a major contributor in maxillary growth.
 The basis for the "septal“ theory is that the pressure-
accommodating expansion of the cartilage in the nasal
septum provides a source for the physical force that
displaces (pushes) the whole maxilla anteriorly and
inferiorly.
 This sets up fields of tension in all the maxillary
sutures. The bones then secondarily, but virtually
simultaneously, enlarge at their sutures in response to
the tension created by the displacement process.

Possible role of cartilaginous nasal septum in downward and forward growth of
the maxillary complex.

FUNCTIONAL MATRIX THEORY: MELVIN
MOSS
 “The functional matrix is primary and the origin,
development , and maintainence of skeletal unit is
secondary, compensatory and mechanically obligatory
response to change in shape and special position of its
related functional matrix”
 Each function is carried out by a soft tissues which are
supported and/or protected by skeletal element.

 Moss points out, the
nasomaxillary bones are
enclosed within an orofacial
capsule.
 The primary expansion of
the functioning
oronasopharyngeal spaces
on a morphogenetic
stimulus brings about
secondary compensatory
expansion of the orofacial
capsule and translation of
nasomaxillary bones

SURFACE REMODELLING
 It results in
increase in size ,Change in shape of bone, Change in
functional relationship

THE MAXILLARY TUBEROSITY & ARCH
LENGTHENING
 Maxilla grows
horizontally by
remodelling of maxillary
tuberosity.
 Deposition occurs on
the posterior facing
periosteal surface of the
tuberosity, endosteal
surface (maxillary sinus)
is resorptive. Cortex
moves posteriorly and
little laterally

The whole maxilla undergoes a simultaneous process of
primary displacement in an anterior and inferior direction as it
grows and lengthens posteriorly and superiorly.

 The growth of bony maxillary arch occurs by 3
processes
1. It lengthens by deposition on the posterior-facing
maxillary tuberosity
2. It grows laterally by deposits on the buccal surface
thus widening the posterior part of the arch
3. It grows downward by deposition of bone along
alveolar ridges and also on the lateral sides,
because this outer surface slopes slightly
downward
The increase in length is primarily because of growth in
posterior border”

As the maxilla is translated downward
and forward, bone is added at the
sutures and in the tuberosity area
posteriorly, but at the same time,
surface modeling removes bone from
the anterior surfaces (except for a small
area at the anterior nasal spine).
For this reason, the amount of forward
movement of anterior surfaces is less
than the amount of displacement. In
the roof of the mouth, however, surface
modeling adds bone, whereas bone is
resorbed from the floor of the nose. The
total downward movement of the
palatal vault, therefore, is greater than
the amount of displacement.

THE CHEEKBONE AND ZYGOMATIC ARCH
It also moves the arches posteriorly and
bilaterally, thus increasing the space between
for overall head and brain enlargement. .
Resorption at
ANTERIOR &
MEDIAL
surface
Deposition at
POSTERIOR &
LATERAL
surface

 The zygoma and cheekbone
complex becomes displaced
anteriorly and inferiorly in
the same directions and
amount as the primary
displacement of the maxilla.
 The growth changes of the
malar process are similar to
those of the mandibular
coronoid process, its
counterpart.

NASAL AIRWAY
 Lining surfaces of the bony
walls and floor of the nasal
chambers are RESORPTIVE
 Produces a lateral and anterior
expansion of the nasal
chambers and a downward
relocation of the palate.
 The maxillary sinus is
resorptive in the lateral wall
and depository in the medial
wall to accomodate nasal
expansion

 The ethmoidal conchae
– depository surfaces
on their lateral and
inferior sides and
resorptive surfaces on
the superior and medial
facing sides of their
thin bony plates
 Move them downward
and laterally
 Expansion of the entire
nasal region.

The breadth of the nasal bridge in the region just below the frontonasal
sutures does not markedly increase from childhood to adulthood. More
inferiorly in the interorbital area, however, the medial wall of each orbit
expands and ballons out considerably in a lateral direction in conjunction with
the considerable extent of lateral enlargement of the nasal chambers

PALATAL REMODELLING
 The external (labial)
side of the whole
anterior part of the
maxillary arch is
resorptive, with bone
being added onto the
inside of the arch, the
arch increases in width,
and the palate becomes
wider according to V
principle

 In early prenatal life: palate is relatively long
 4th month: widens as a result of midpalatal
suture growth and appositional growth along the
alveolar margins.
 Growth of midpalatal suture occurs between 1
and 2 years of age. It is larger in its posterior than
in its anterior part, so that the posterior part of
the nasal cavity widens more than the anterior
part.

 Lateral appositional growth: continues until 7 years of
age and the palate achieves its maximum anterior width.
 Posterior appositional growth continues after the lateral
growth has ceased, so that the palate becomes longer
and wider during late childhood.
 The appositional growth of the alveolar process
contributes to deepening as well as widening of the vault
of the bony palate at the same time adding to the height
and breadth of maxilla.

LACRIMAL SUTURE: KEY FACTOR FOR
MAXILLARY GROWTH
 The lacrimal bone is a diminutive flake of a bony island
bounded by sutural connective tissue contacts
separating it from the other bone.
 As all these other separate bones enlarge or become
displaced in many directions, at different rates and
different times, the sutural system of the lacrimal
bone provides for the “slippage” of the multiple bones
along sutural interfaces as they all enlarge
differentially
 This is made possible by collagenous linkage
adjustments within the sutural connective tissue.

ORBITAL GROWTH
 Follows V principle
 Sutural bone growth occurs
at the many sutures within
and outside the orbit, the
orbital floor is displaced
and enlarges in a
progressive downward and
forward direction along
with the rest of the
nasomaxillary complex.
.

The floor of the orbit moves
upward as the whole maxilla
displaces inferiorly.
Deposition takes place on the
intraorbital (superior) side of
the orbital floor and
resorption on the maxillary
(inferior) sinus side.
Thus, the orbital and nasal
floors are necessarily
displaced in the same
direction because they are the
parts of the same bone, but
they undergo remodelling
relocation movements in
opposing directions.

THE KEY RIDGE
 Major change in surface
contour occurs along the
vertical crest just below the
malar protuberance. This
crest is called the "key
ridge”.

 Part of the bony arch in area b is concave, and
the labial (outside) surface faces upward, rather
than downward. The resorptive nature of this
surface provides an inferior direction of arch
remodelling in conjunction with the downward
growth of the palate. This is in contrast to area a,
which grows downward by periosteal deposition.

VERTICAL DRIFT OF TEETH
 The process of drift moves
the whole tooth and its
socket; that is, the tooth
does not drift vertically out
of its alveolar housing as it
does in eruption (or as
implicit in the term
"extrusion").
 Rather, in vertical drift, the
socket and its resident
tooth drift together as a
unit

 The horizontal and the vertical distances moved by the
socket, its tooth, and the periodontal membrane can
be substantial. By harnessing the vertical drift
movement, the orthodontist can more readily guide
teeth into calculated positions, thereby taking
advantage of the growth process ("working with
growth")

Vertical drift of each tooth
in its own alveolar socket
Passive carrying of the
maxillary dental arch

 The two-way combination of
(1) forward remodeling of the nasal region and superior
orbital rim together with
(2) backward remodeling growth of the inferior orbital rim
and the malar area, and
(3) the essentially straight downward remodeling of the
premaxillary region, all combine to produce a
developmental rotation in the aligllment of the whole of
these middle and upper facial regions
TOPOGRAPHIC MATURATIONAL CHANGE IN
THE CHILDHOOD-TO-ADULT FACE

The facial contours become opened, the protrusions
more prominent, and the depths all increased.

AGE CHANGES IN MAXILLA
 AT BIRTH
 Transverse and anteroposterior diameters >
vertical diameter
 Frontal process is well marked
 Body of bone-little more than alveolar process
 Tooth socket-close to floor of orbit
 Maxillary sinus presents the appearance of a
furrow on lateral wall of nose

IN ADULT
 The vertical diameter is the greatest due to
developed alveolar process.
 Increase in the size of sinus
 Maxillary sinus
With increasing age it expands
Becomes more and more pneumatized down
around maxillary teeth

IN OLD AGED
 The bone reverts to some measure to its infantile
condition as:,
 Its height is diminished
 After the loss of the teeth the alveolar process is
resorbed

AGE-RELATED ARCH WIDTH CHANGES IN
MAXILLA
 Bishara et al. found that for maxillary arch,
intercanine width increases between 3 and 13
years by 6 mm but decreases by 1.7 mm between
13 and 45 years.
 On the other hand, intermolar width increases by
2 mm between 3 and 5 years and by 2.2 mm
between 8 and 13 years but decreases by 1 mm
by 45 years of age.

DEVELOPMENTAL ANOMALIES
AFFECTING MAXILLA
 CLEFT LIP: Failure of
maxillary prominence to
fuse with the medial nasal
process of the affected side:
Unilateral cleft lip.
 Failure of maxillary
prominences to meet and
unite with medial nasal
processes on both sides:
Bilateral cleft lip.
 Failure of medial nasal
processes to join and form
the inter maxillary
segments : Median Cleft Lip

 OBLIQUE FACIAL CLEFT
Non fusion of the
maxillary and lateral
nasal processes gives to
a cleft that runs from
the medial angle of the
eye to the mouth. In
this case, the naso
lacrimal duct is not
formed.

 Inadequate fusion of
maxillary and
mandibular processes
with one another:
Macrostomia.
 Lack of fusion may be
present only on one
side : Lateral facial cleft
 Excessive
fusion:Microstomia

 BIFID NOSE: Associated
with a median cleft lip,
there may be a bifid
nose, occurring due to
the bifurcation of the
frontonasal process.
Sometimes, one half of
it may be absent
altogether.

PIERRE ROBIN SYNDROME
 Pierre Robin sequence (PRS) is
classically described as a triad
of micrognathia, glossoptosis,
and airway obstruction.
 The genetic causes for some
of the isolated cases may
include mutations or deletions
of parts of the DNA in
chromosome 17.
 This gene provides
instructions for making a
protein that plays an important
role in the formation of many
different tissues and organs
during embryonic development.

MANDIBULOFACIAL DYSOSTOSIS:
 The entire first arch remains underdeveloped on either
one, or both sides.
 This effects the lower eyelid, the maxilla, the mandible
and the external ear.
 The prominence of the cheek is absent and the ear may
be displaced ventrally and caudally
 There may also be occurrence of cleft palate and faulty
dentition.
 Also known as Treacher Collin Syndrome or First Arch
Syndrome.

In the Treacher Collins syndrome (also called mandibulofacial dysostosis), a
generalized lack of mesenchymal tissue in the lateral part of the face is the major
cause of the characteristic facial appearance. Note the underdevelopment of the
lateral orbital and zygomatic areas. The ears also may be affected. Patient at age 12
before (A) and immediately after (B) surgical treatment to advance the midface.
Note this patient’s ear deformity, which usually is concealed by hair. (C and D) Age
16. Note the change in the lateral orbital margins.

CROUZON SYNDROME
CRANIOFACIAL
DYSOSTOSIS
Premature closure,
especially of coronal
suture, occasionally
lambdoidal.
Mutation in fibroblast
growth factor receptor
2 on chromosome 10 .
This syndrome arises
because of prenatal
fusion of the superior
and posterior sutures
of the maxilla along the
wall of the orbit.

OCULOAURICULOVERTEBRAL
SYNDROME
 HEMIFACIAL
MICROSTOMIA
Craniofacial
abnormalities involving
the maxillary , temporal
and zygomatic bones
which are small and flat

GENETIC INFLUENCES
 In this 14-year-old girl
with moderately severe
achondroplasia, note
the deficient midface,
particularly at the
bridge of the nose. This
results from decreased
growth of cartilage in
the cranial base, with a
resulting lack of forward
translation of the
maxilla

CONCLUSION
 Knowledge of growth is also important because, whenever
possible, orthodontists should try to mimic growth when
planning treatment.
 Provides the biological limits within which treatments can
be performed.
 An understanding of growth makes it possible to estimate
morphologic changes that might be expected to occur
after orthodontic treatment.
 Knowing how an individual patient grew before treatment
provides considerable information about how he or she
might be expected to grow after treatment.

REFERENCES
 Orthodontics diagnosis and management of
Malocclusion & dentofacial deformities – O P
Kharbanda, 2 edition
 Textbook of Orthodontics, Samir E. Bishra
 Contemporary orthodontics by William Proffit, 5
edition
 Textbook of craniofacial growth, Sridhar Premkumar
 Orthodontics current Principles and Techniques by
Graber, Vanarsdall, Vig, Fifth Edition
 Essentials of facial growth – Enlow

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