BASIC PRINCIPLES AND

METHODS OF STUDYING
GROWTH, GROWTH SPURTS
AND AFFECTING FACTORS
SUBMITTED BY-
Jagriti
PG ( first year )
DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS
 CONTENTS

 Definitions  Factors affecting physical

growth
 Methods of studying physical
growth  Concepts of growth
• Measurement approach  Canalised and catch up
growth
• Experimental approach
 Growth and growth studies
 Basic principles of growth and
development  Growth rotation
• Pattern  Methods of growth
assessment
• Variability
 Mechanism of bone growth
• Timing
 References
 Growth was conceived by anatomist, born to a
biologist, delivered by a physician, left on a chemist’s
doorstep and adopted by a physiologist. At an early
age she eloped with a stastician , divorced him for a
psychologist and is now being wooed , alternately and
concurrently by an endocrinologist, a pediatrician, a
physical anthropologist and an educationalist, a
biochemist, a physicist, a mathematician, an
orthodontist, a eugenicist and the children’s bureau !
- Graber
DEFINITIONS- GROWTH
DEFINITIONS- DEVELOPEMENT
 CORELATION BETWEEN GROWTH AND
DEVELOPEMENT

 Growth is basically anatomic phenomenon and quantitative in

nature
 Development is basically physiological phenomenon and
qualitative in nature
 METHODS OF STUDYING PHYSICAL GROWTH
2 WAYS

MEASUREMENT EXPERIMENTAL
APPROACH APPROACH
Acquiring Analysis of
measured data measured data Vital staining
Craniometry Autoradiography
Anthropometry Radioisotopes
Cephalometric radiology Implant radiology
3- dimensional imaging
MEASUREMENT
APPROACHES
 CRANIOMETRY

 Craniometry involves measurement of skulls found

among human skeletal remains.
 It has the advantage that rather precise measurements
can be made on dry skulls whereas the big
disadvantage is that such a growth study can only be
cross sectional.
ANTHROPOMETRY

 Anthropometry is a technique, which involves measuring

skeletal dimensions on living individuals.
 Various landmarks established in the studies of dry skull
are measured in living individuals by using soft tissue
points overlying these bony landmarks.
 Despite this shortcoming the most important advantage
is that the study can be longitudinal, wherein the growth
of an individual can be followed directly over a period
of time with repeated measurement without damaging
the subject.
CEPHALOMETRIC RADIOLOGY

 Cephalometric radiography is a technique that depends on

precise placement of the individual in a cephalostat so that
the head can be precisely oriented before making
radiograph with equally precise control of magnification.
 Advantage - direct bony measurements as seen on the
radiograph can be made over a period of time for the same
individual.
 Disadvantage- it produces a two dimensional representation
of a three-dimensional structure making it impossible to make
all the measurements.
3- DIMENSIONAL IMAGING

 CAT allows 3D
construction of cranium
and face.
 Recently CBCT, rather
than CT has been
applied to scans of head
and face.
MRI also provides 3D images that can be useful in studies of
growth, with the advantage that there is no radiation
exposure with this technique.
MRI

 Advantage
No radiation exposure
 Applied to analysis of
growth
Changes by functional
appliance
3D photography now make possible much more accurate
measurements of facial soft tissue dimensions and changes
HAND AND WRIST RADIOGRAPH
EXPERIMENTAL
APPROACHES
VITAL STAINING

 Vital staining, introduced first by John Hunter in the

eighteenth century.
 Here growth is studied by observing the pattern of
stained mineralized tissues after the injection of dyes into
the animal.
 Alizarin was found to be the active agent and is still
used for vital staining studies.
 AUTORADIOGRAPHY

 Autoradiography is a technique in which a film emulsion

is placed over a thin section of tissue containing
radioactive isotope and then is exposed in the dark by
radiation.
 After the film is developed, the location of radiation
indicates where growth is occurring.
RADIOISOTOPES

 These elements when injected into tissues get

incorporated in the developing bone and act as in vivo
markers and can then be located by means of a Geiger
counter, e.g. 99mTc, Ca-45 labeled component of
protein, e.g. proline.
IMPLANT RADIOGRAPHY

 Herein, inert metal pins (generally made of titanium) are

inserted anywhere in the bony skeleton including face
and jaws.
 Superimposing radiographs (cephalograms in case of
face) on the implants allow precise observation of both
changes in the position of one bone relative to another
and changes in external contour of the individual bone.
BASIC PRINCIPLES OF GROWTH AND
DEVELOPMENT
 PATTERN

 PATTERN: in growth represents proportionality.

 every species follow a pattern of development peculiar
to it.
 It is similar to every individual.
 DIFFERENTIAL GROWTH-
CEPHALOCAUDAL GRADIENT OF GROWTH

 It means there is an axis of increased growth

extending from head towards the feet.
CEPHALOCAUDAL GRADIENT OF
GROWTH WITHIN HEAD AND FACE
DIFFERENTIAL GROWTH- SCAMMON’S
CURVE OF GROWTH
GROWTH- VARIABILITY

 Refers to deviation from normal pattern.

 Growth variability can be predicted by growth chart
which helps-
1. To evaluate the present growth status of individual
2. To follow the child’s growth over a period of time.
GROWTH- TIMING

 Biological growth of different persons are set differently.

TIMING variation is mostly seen is adolescent
age(growth spurts).
 It is influenced by:
genetics
sex related differences
physique related
environmental influences
 HEREDITY

HORMONES SEX

EXERCISE NUTRITION

PSYCHOLOGICAL
DISTURBANCES
ILLNESS FACTORS
AFFECTING
PHYSICAL
CLIMATIC AND
SEASONAL
EFFECTS
RACE GROWTH

SOCIO-
SECULAR TRENDS ECONOMIC
FACTORS
FAMILY SIZE AND
BIRTH ORDEWR
SOME CONCEPTS OF GROWTH

 Concepts of normality : normality is what that is usually

expected , ordinarily seen or is typical.
normality changes with age
Rhythm of growth : according to HOOTON
not a steady and uniform process
(wherein all parts of body enlarges at same rate
But it maintains a rhythm. )
Growth spurts :
There are periods of sudden rapid increase.
The rate of growth is more rapid at the beginning of
cellular differentiation, increases until birth and decreases
there after . This uneven activity is responsible for the
interpretation of growth as appearing in “ spurts”.
BJORK (1975):
1. Prenatal – just before birth.
2. Postnatal
one year after birth
Mixed dentition growth spurt
females: 7-9 years
males : 8-11 years
Pre Pubertal growth spurt
females: 11-13 years
males: 14-16years
CLINICAL SIGNIFICANCE OF GROWTH
SPURTS
 Treatment of skeletal discrepancies is more
advantageous in mixed dentition period.
 Bone is expandable in growth phase and procedures
like maxillary expansion can be carried out though it
can pose a problem in treatment of cleft palate.
 Pubertal growth spurt is best time is cases of
predictability, treatment direction, time and
management.
DIFFERENTIAL GROWTH: different organs is body
grows at different time period
2 important aspects of growth are:
Scammon's curve of growth
Cephalo caudal gradient of growth
 If an organism grew in an
environment which is feasible
for unrestrained growth, the
growth would follow a
particular predefined curve,
largely dictated by genetic
makeup, until the final size and
shape are reached , as if
growth were channeled along
a predefined canal. This
phenomenon was called
canalization (homeorrhesis) by
Waddington.
CATCH UP GROWTH

It is defined as the height velocity that exceeds the normal

limits for the age for at least 1 year after a period of
depressed growth.

OR
Catch up growth may be defined as growth that occurs
following an insult or injury which leads to temporary
cessation or reduction of growth.
  The organization and complexity of growth and
development is clearly evident in the changes
that take place in the head and face
 The basic control of growth, both in magnitude
and timing, is located in the genes.
GROWTH AND
GROWTH STUDIES  The main potential for growth lies in the genes.
IN  Many growth studies have been done over the
years and the information received from them
ORTHODONTICS- has been priceless.
A REVIEW  Extensive research work in growth required large
scale growth studies

 ( Kulshrestha, R., et al. Growth and Growth Studies in Orthodontics - A Review. (2016) J Dent Oral
Care 2(4): 1- 5.)
 Bolton-brush growth study

 The Bolton-Brush Growth Study consisted of the world’s most

extensive data source of longitudinal human growth.
 The Brush Study was started in 1926 by Prof. T Wingate Todd
 The radiographs were taken of the same individuals on a yearly
basis for the sole purpose of determining how the body grows .
 The Bolton-Brush Growth Studies have become one of the worlds
oldest and longest running studies on normal development and to
be a healthy child and now adult.
The Burlington growth
study
 The Burlington Growth Study was
the creation of Dr. Frank
Popovich, Professor, past
Director of Burlington Growth
Centre from 1961 to 1989.
 The most important observation
relates to the dynamics of facial
growth and how the treatment
will change and modify the
growing face. Faces grow either DR. FRANK POPOVICH
horizontally, vertically or
balanced manner.
Other studies done were-

 The Michigan growth study

 The Denver child growth study
 The Iowa child welfare study
 The Forsyth twin study
 The Meharry growth study
 The Krogman Philadelphia growth study
 The Fels growth study
 Many growth studies which have been done, have given
us a new perspective about craniofacial growth.
 It has helped us to evaluate growth and development of
different individuals of different age groups.
 Some growth studies have given us a foundation on
which to build on and assess growth in different stages of
individuals e.g. Bolton brush study, Burlington growth
study, Bjork implant studies.
 In all the study of growth and development is very
important for the orthodontist as it helps him to diagnose
and assess the case and plan the best treatment plan
possible for the patient.
DEFINITION

 Growth prediction can never be accurate especially

when the child is growing (Proffit).
 Growth prediction can be defined as the forecast of
growth related changes with the objective of predicting
the direction and the amount of growth of maxilla and
particularly mandible as well as timing of adolescent
growth period.
 1. To intercept and correct malocclusion.

2. As patients educational aid.

3. VTO.

Need for
4. Tool for orthodontic treatment planning.
growth
prediction 5. Response to particular treatment can be
predicted.

6. To plan for retention period.

METHODS OF PREDICTION

 (Hirschfield 1971)

 1. Theoretical
 2. Regression
 3. Experimental
 4. Time series
Growth prediction in orthodontics

 Growth prediction is usually not done for all cases but

mainly for perverted cases.
 Every child has a genetically determined pattern which
is acted upon by environmental influences.
 Growth prediction often does not satisfy the purpose it
was originally invented for.
 Development of satisfactory treatment plan is seldom
important.
HUNTERIAN CONCEPT
 Given by john hunter.
 He noticed linear growth of mandible(lengthening).
 Resorption in anterior border and deposition in posterior
border.
 Gnomonic growth and logarithmic
spiral
Bjork
 He proved that maxilla and mandible underwent rotational
growth.

Moss and Salentejin

 They predicted that mandibular rotation grows in spiral path.
 Moss predicted that mandibular growth is along a logarithmic
spiral.
 He actually inspired from gnomonic growth concept of D’arcy
Thompson.
What is gnomonic growth ?

The portion of increment which when added doesnot

alter shape but only produces an increase in size is called
gnomon in Greek by Aristotle.

 D ‘arcy Thompson has explained from chambered

nautilus .
 1.shell grows in size with no change in shape .
 2.can be described by a curve which is called
logarithmic spiral or equiangular spiral.
Arcial growth of mandible

Given by rickets
 An arc of growth can be constructed for every
individual depending on the length of the core of the
mandible.
 He used points which are immune to surface deposition
and resorption.
Drawbacks of arcial growth prediction

 It relies heavily on the operators skill in tracing the

cephalogram.
 Mitchell & Jordan (1975) concluded Ricketts uses
chronological age rather than the skeletal age. If the
patient is in a growth spurt or lag phase it will alter the
result.
JOHNSTON’S GRID
TODD’S
VISUAL TREATMENT OBJECTIVE
G ROWTH ROTATIONS

 The phrase growth rotation was introduced in 1955 by

Bjork, who used it to describe a particular phenomenon
occurring during the growth of the head.
Bjork’s studies on growth rotation
AJO 1969
 Mixed longitudinal study begun in 1951 at Dept of
Orthodontics, Royal Dental College, Copenhagen.

 Sample: 100 persons of each sex.

Age range 4-24 years.
Normal Healthy children with &
without malocclusion, & also children
with pathologic conditions.
Sites for Implant
placement
Region 1: One pin is
placed on the anterior
aspect of the symphysis,
as low down as possible
in the midline beneath
the germs or root tips.
This pin has proved to
be highly stable, but
may be exposed by
resorption, if placed too
high in the supramental
region.
 Region2: Two pins are inserted on the right side of the
basal part of the mandible, under the 1st premolar and
2nd premolar (or 1st molar), beneath their germs or root
apices.
 Region 3: One pin is placed on the external aspect of
the right ramus, on a level with occlusal surfaces of the
molars. This may be gradually exposed by resorption
and a new one needed.
 Region 4: One or two pins are also inserted in the
mandibular base on the left side, under the 2nd premolar
or 1st molar.( By using small pins on the right side and
larger ones on the left, they can be recognized easily.)
MANDIBULAR GROWTH PATTERN

 It has been confirmed by the implant technique that

growth in length of the mandible in mandible occurs
essentially at the condyles.
 The anterior aspect of the chin is extremely stable, no
growth having been found here except in a few cases
of pathologic development.
 The thickening of the symphysis, therefore, normally
takes place by apposition on its posterior surface.
 On its lower border there is likewise apposition, which
contributes to the increase in height of the symphysis.
 As the endosteal resorption in this area does not occur
at the same rate as the apposition on the outer surface,
a pronounced apposition will be reflected in an
increase in the thickness of the cortical substance.

 Below the angle of the mandible there is normally

resorption, which may be very pronounced.

 In some cases there is, instead, apposition on the lower

border at the angle of the jaw. These appositional and
resorptive processes result in an individual shaping of
the lower border of the mandible, which characterizes
the type of growth.
 The mandibular canal is not remodeled to the same
extent as the outer surface of the jaw, and the
trabeculae related to the canal are therefore relatively
stationary. The curvature of the mandibular canal,
therefore, reflects the earlier shape of the mandible.

 The lower border of a developing molar germ in the

mandible appears to be fairly stationary until the roots
begin to form. This means that, for a period, the tooth
germ may serve as a natural reference structure in the
growth analyses of the mandible.
Types of growth rotation

by Bjork

AJO 1969
 FORWARD ROTATION

They can occur in three ways

Type I.
In this type there is a
forward rotation about centers
in the TMJ which gives rise to a
deep-bite, in which the lower
dental arch is pressed into the
upper, resulting in
underdevelopment of the
anterior face height.
The cause may be occlusal
imbalance due to loss of teeth
or powerful muscular pressure.
This lowering of the bite may
occur at any age.
 TYPE 2
Forward growth rotation of
the mandible about a
center located at the incisal
edges of the lower anterior
teeth
It is due to the combination
of marked development of
the posterior face height
and normal increase in the
anterior height.
The posterior part of the
mandible then rotates away
from the maxilla.
 Because of the vertical direction of condylar growth, the
mandible is lowered more than it is carried forward.
 Because of the muscular and ligamentous attachments,
the lowering takes place as a forward rotation in relation
to the maxilla, with the center at the incisal edges of the
lower incisors.
 The eruption of the molars keeps pace with the rotation.
 The increase in the posterior face height has two
components.
 The first is the lowering of the middle cranial fossae in
relation to the anterior one as the cranial base bends,
the condylar fossae then being lowered.
 The second component is the increase in the height of
the ramus, which is pronounced in the case of vertical
growth at the mandibular condyles. Only the latter
component, which is the larger one,
TYPE-3
In the case of large maxillary
overjet or mandibular overjet,
the center of rotation no
longer lies at the incisors but is
displaced backward in the
dental arch, to the level of the
premolars.
In this type of rotation the
anterior face height becomes
underdeveloped when the
posterior face height
increases.
The dental arches are pressed
into each other and basal
deep-bite develops.
The rotation also affects the position of the lower posterior
teeth in relation to the upper teeth.

Forward growth rotation thus causes the lower posterior

teeth to be more upright than usual in relation to the upper
posterior teeth, with an increase in interpremolar and
intermolar angles.
  Backward rotation of the mandible is
less frequent than forward rotation and
BACKWARD has been examined by the implant
method in considerably fewer subjects.
ROTATION Two types have been recognized:
TYPE- 1

 Here the center of the backward

rotation lies in the temporomandibular
joints.
 This is the case when the bite is raised by
orthodontic means, by a change in the
intercuspation or by a bite-raising
appliance, and results in an increase in
the anterior face height.
TYPE- 2

 Backward rotation here occurs about a

center situated at the most distal
occluding molars. This occurs in
connection with growth in the sagittal
direction at the mandibular condyles.
 As the mandible grows in the direction of
its length it is carried forward more than
it is lowered in the face, and because of
its attachment to muscles and ligaments
it is rotated backward.
STRUCTURAL
SIGNS OF
GROWTH
ROTATION
It is important to detect extreme types of mandibular rotation
occurring during growth.

Seven structural signs of extreme growth rotation will be

considered in relation to the condylar growth direction.

Not all of them will be found in a particular individual, but the

greater the number that are present, the more reliable the
prediction will be.

Moreover, it is evident that these signs are not so clearly

developed before puberty.
(1) Inclination of the
condylar head
 Forward inclination forward
rotation
 Backward inclination
backward rotation

 It may not be easy to identify

on the cephalometric
radiogram, where part of the
condyle is masked
(2) Curvature of the mandibular canal

In the vertical type of condylar growth, the

curvature of the canal tends to be greater than
that of the mandibular contour, including the
angle of the jaw

Whereas in the sagittal type the opposite is

generally the case. The canal may then be
straight or, in pathologic cases, it may even
curve in the opposite direction.
 (3) Shape of lower border of mandible
 The shape of the lower border
of the mandible is highly
characteristic.
 In vertical condylar growth, the
pronounced apposition below
the symphysis and the anterior
part of the mandible produces
an anterior rounding, with a
thick cortical layer, while the
resorption at the angle
produces a typical concavity.
 In sagittal growth, the anterior
rounding is absent and the
cortical layer is thin, while the
lower contour at the jaw angle
is convex
 (4) Inclination of symphysis
 In the vertical type of growth,
the symphysis swings forward in
the face and the chin is
prominent,
 While in the sagittal type it is
swung back, with a receding
chin.
 The evaluation is complicated
by the simultaneous
remodeling of the alveolar
process in the opposite
direction, as is exemplified by
the cranium with the open-bite.
(5) Inter-incisal angle:
Increased in forward rotation.
Decreased in backward rotation.

(6) Inter-molar angle:

Increases in forward rotation ( lower posteriors upright)
Decreases in backward rotation ( lower posteriors mesially inclined)

(7) Anterior lower face height:

Decreased in forward rotation.
Increased in backward rotation.
COMPONENTS OF ROTATION
(1) Total Rotation

- Rotation of the mandibular corpus

measured as a change in inclination of
implant line relative to the anterior cranial
base.
- It is largely determined by amount &
direction of growth in the condyles.
(2) Matrix Rotation

- Rotation of the soft tissue matrix of the

mandible relative to cranial base (soft
tissue matrix defined by tangential
mandibular line).
- Its center of rotation is at condyles.
- Matrix rotation is composite of articular
growth + remodelling.
(3) Intramatrix rotation

 The difference between the total

rotation and the matrix rotation is an
expression of the remodeling at the
lower border of the mandible.
 It is identified by the change in
inclination of an implant or reference
line in the mandibular corpus relative
to the tangential mandibular line.
 The intramatrix rotation has its center
somewhere in the corpus.
 In an effort to simplify
and clarify a complex
and difficult subject
Proffit suggested few
terminologies
 considering mandible
first,
 Core of the mandible
– is the bone that
surrounds the inferior
alveolar nerve.
 Rest of mandible
consists of several
functional processes
 The implants are
placed in core of
mandible away from
functional processes
Internal Rotation
 The rotation of core
of mandible relative
to the cranial base.
This was called total
rotation by Bjork and
Skieller
 It varies between
individuals ranging
up to 10 to 15
degrees
Total rotation
 Change in mandibular plane angle which is the rotation
around condyle is termed as Total Rotation
 Total rotation - forward rotation of 2 to 4 degrees
External rotation
 The reason that internal rotation is not expressed
is that, surface changes, i.e. remodeling in lower
border of mandible tend to compensate
 Posterior part of lower border of mandible is area
of resorption and anterior part of lower border is
unchanged or undergoes slight apposition
 Alteration in rate of tooth eruption is also a part
of external rotation
 ROTATIONS OF MAXILLA
 Internal rotation: This is the rotational pattern that occurs in
the core of the maxilla. This is also called intramatrix
rotation. The internal rotation is similar to intramatrix
rotation of mandible.
 External rotation: Simultaneous to internal rotation of
maxilla, varying degrees of resorption of bone on the nasal
side and apposition of bone on the palatal side in anterior
and posterior parts of the palate also takes place. Similarly,
variations in the amount of eruption of the incisors and
molars occur. All these changes collectively contribute to
external rotation.
 Forward growth rotation: This condition occurs either due
to excessive internal rotation or lack of normal
compensatory external rotation or a combination of
both.
 Backward rotation: Backward rotation of maxilla is
exactly opposite to that of forward rotation where there
is downward and backward tipping of the anterior end
of the palatal plane and the maxillary base.
Interaction
between jaw
rotation and
tooth eruption
 The rotational pattern of jaw growth influences
magnitude of as well as direction of eruption and
ultimate anteroposterior position of incisor teeth

Maxilla
 Forward rotation tends to tip the incisors forward
increasing their prominence
 Backward rotation directs anterior teeth more
posteriorly , relatively up righting them and decreasing
their prominence
Movement of teeth relative to cranial base could be
combination of two different components
 Translocation - as tooth is moved along with
jaws it is embedded and
 True eruption - movement within the jaw

 Translocation contributes about half of total maxillary

movement during adolescent growth
Mandible
 Normal internal rotation of mandible carries jaw up in front,
tending to direct the incisors more posteriorly

 Because internal jaw rotation tend to upright the incisors, the

molars migrate further mesially than do incisors

 This is reflected in decrease in arch length that normally occurs

 Since forward internal rotation of mandible is greater, decrease

in arch length is greater in mandible than in maxilla
METHODS OF GROWTH ASSESSMENT

 WEIGHT FOR AGE

 HEIGHT FOR AGE
 HEIGHT FOR WEIGHT
 MID – ARM CIRCUMFERENCE
Mechanism of bone growth

 Endosteal and periosteal bone formation

 Relocation and remodelling
 V principle
 Surface principles
 Growth fields
 Growth centres
Endosteal and periosteal bone formation

 Half of the cortical plate of cranial and facial bone is

formed by outer surface i.e endosteum and other half
by inner surface i.e periosteum
 If the direction of growth remains constant right, right
cortical plate is formed periosteally and left plate
endosteally
 Both shift in unison in
the direction of growth
Relocation and Remodeling

 Due to new bone deposition on the existing surface ,all

the other parts undergo shift in relative position –the
movement is called relocation
 As a result of this process, further adaptive bone
remodeling is necessary to adjust the size and shape of
area to the new relationship
 Selective resorption and apposition processes remodel
to conform to new physiological loading
 Remodeling occurs secondary to displacement process
As a result of relocation and
Remodeling the marked
area is translocated
From posterior to anterior
Border of ramus without
Changing its own position
 Remodeling process of the
ramus takes place towards
posterior .the body of mandible
Becomes lengthened by
Remodeling parts of ramus
Which simultaneous shifts in
Backward direction
“V” Principle
 Since many facial bones have “v” configuration or v- shaped
regions it is an important principle
 Such areas grow by bone resorption on outer surface V and
deposition on inner side
 The V moves away from its narrow end and enlarges in overall
size
Surface Principle

 The surface principle stated that bone sides which face

the direction of growth are subjected to deposition and
those opposed to it undergo resorption
 These processes always take place on contralateral
bone surfaces so that the cortical plate follows the
course of growth
Growth field

 Bone growth is controlled by so called growth fields

 These fields are distributed in mosaic like pattern across
surface of given bone and have either depository or
resorptive activity

pink field=bone
deposition

blue field=bone
resorption
 Growth centers
These are very active growth fields which are significant to the growth

Processes such as :-
cranial and facial sutures
Mandibular condyles
Maxillary tuberosity
Alveolar process
Synchondroses of cranial base
 REFERENCES
 CONTEMPORARY ORTHODONTICS :WILLIAM PROFFIT
 ESSENTIALS OF FACIAL GROWTH :DONALD H. ENLOW & MARK G. HANS
 TEXTBOOK OF ORTHODONTICS: SAMEERR E. BISHARA
 HANDBOOK OF ORTHODONTICS: ROBERT E. MOYERS
 ORTHODONTICS PRINCIPLES AND PRACTICE : GRABER AND SAUNDERS
 TEXTBOOK OF CRANIOFACIAL GROWTH: SRIDHAR PREMKUMAR
 ORTHODONTICS THE ART AND SCIENCE: S.L. BHALAJHI
 ORTHODONTICS DIAGNOSIS AND MANAGEMENT OF MALOCCLUSION AND
DENTOFACIAL DEFORMITIES: OM PRAKASH KHARBANDA
 Moss, M. L., & Salentijn, L. (1969). The primary role of functional matrices in facial
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 Growth prediction from posture - Solow and Siersbæk-Nielson AJO-DO May 1992
 Kulshrestha, R., et al. Growth and Growth Studies in Orthodontics - A Review. (2016)
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