Good

morning
GROWTH ASSESSMENT
&
ITS CLINICAL
SIGNIFICANCE
 CONTENTS
• Introduction
• Types of growth data
• Methods of gathering growth data
• Evaluation of growth data
• Basic tenets of growth
• Growth analysis by superimposition technique
• Growth assessment parameters
• Clinical implications
• conclusion
 INTRODUCTION

GROWTH : In biology, growth is increase in size or

Mass accompanying normal development .
The assessment of craniofacial structures forms a
part of Dentistry & in various other disciplines.
each person has a unique growth pattern that is
influenced by their genetic make up and as well as
external environment factors such as function,
disease, habits & orthodontic treatment.
 TYPES OF GROWTH DATA
• DATA :a collective recording of observations either
numerical or otherwise is called as ‘data’.

• Main source of data :surveys , experiments ,records

• Qualitative : sex ,mal- • Quantitative : like arch

occlusion, cavity length, arch width,
flouride concentration
in water supply
• Types of growth data:
a) Direct data: size of teeth – Boley’s guage
b) Indirect growth measurements – photographs
dental casts ,cephalograms
c) Derived data - by comparing atleast two other
measurements:
METHODS OF GATHERING
GROWTH DATA
• LONGITUDINAL STUDIES:

Measurement made of the same person or group at regular intervals

through time are longitudinal measurements.

• Advantages:
 Studying the natural history of disease &its outcome.
 Specific developmental pattern of an individual can be studied.

• Disadvantages:
 Time
 Expense
 Attrition
• CROSS-SECTIONAL STUDIES
measurement made of different individuals or
different samples & studied at different
periods
Advantages:
 Quicker
 Allows repeating of studies more rapidly
 Less costly

• SEMILONGITUDINAL STUDIES
 METHODS FOR STUDYING
PHYSICAL GROWH
• Measurement approach
Craniometry
Anthropometry
cephalometry
• Experimental approach
Vital staining
Implant radiography
• Others
Electromyography
Natural markers
Radio isotopes
Comparitive anatomy
Genetic studies

• Craniometry : originally used to study the

Neanderthal & Cromagnon peoples skulls , found
in European caves in 18 & 19 century
• ANTHROPOMETRY:

 various landmarks established in studies of dry skull are

measured in living individuals simply by using soft tissue
points overlying these bony landmarks.

 Farkas in 1987 provided new data for the human facial

proportions and change in time
• CEPHALOMETRIC RADIOLOGY:

In 1931 ,Boardbent in U.S.A & Hofrath in Germany

simultaneously presented a standardized cephalometric
technique using cephalostat.

Allows a direct measurement of bony skeletal dimensions.

 Growth studies can be done by superimposing a tracing /

digital model of a later cephalogram on an earlier one.

Disadvantage: it produces a 2-dimensionalrepresentationof a 3-

dimensional structure.
 Purpose of Cephalometrics
• Study craniofacial
growth
• Diagnosis
• Planning orthodontic
treatment
• Evaluation of treated
cases
LANDMARKS
 GROWTH ANALYSIS BY
SUPERIMPOSITION TECHNIQUE
• Sella tursica & the cribriform plate remain unchanged
after the fifth year of life.

• Growth changes of facial skeleton can be evaluated by

superimposing cephalometric radiographs on these stable
structures

• The following superimposition approach offers a sound &

practical way of incorporating these structures in
evaluation of facial growth.
• T-point – the most superior
point of anterior wall of
sella tursica
• C-point – the most
anterior point of cribriform
plate at junction with nasal
bone.’nasion’ may be used if
C-point is not detectable
• L-point – the most
inferior point of sellatursica
• TC line a solid formation is provided through
the shape of triangle
• Cephalometric radiographs are taken at the
age of 9 / 10 yrs / at the initial visit at the
office and at least 6 months after the initial
visit,
• On super imposition two triangles ,the lower
sides of triangle may not necessarily fit right
on top of each other.

• G- line A line connecting the T-point with

gnathion, used as growth line.
• Advantage:
 In diagnosis of abnormal skeletal development
in both dimensions

• Finally in evaluating the patient’s growth, the

clinician ought not to ignore the nose.
• Class I subjects – straight nose
• Class II subjects –more pronounced elevation
of nasal bridge.
• Class III subjects – concave configuration of
nose along the dorsum
• Very small increments of growth is noticed
between the ages of 18 – 22 yrs
 AUTOMATIC
CEPHALOMETRIC ANALYSIS
• Two approaches may be used to perform a
cephalometric analysis

a) manual approach b) computer aided approach

•
conclusion

• automatic landmarking is the first & last step in development

of a completely automatic cephalometric analysis.

• Four catagories based on techniques / combination of

techniques have been employed.
• Image filtering plus knowledge based
• Model based approaches
• Soft computing approaches
• Hybrid approaches
 The systems described are not accurate enough to
allow their use in clinical purpose as errors in
landmark detection were greater than those
expected with manual tracing.

( The angle Orthodontist vol 78,1,jan

2008 ,R.R.J COUSLEY,E.G.RANT et al )
• THREE DIMENSIONAL IMAGING:
 Computed axial tomography allows 3-D
reconstruction of cranium, face.

• ANALYSIS OF MEASUREMENT DATA:

 Both anthropometric and cephalometric data can be

expressed cross-sectionally rather than longitudinally
 Experimental studies
• VITAL STAINING:
Originated by the great english anatomist
‘John Hunter’ in 18 century.

 Skeletal growth can be assessed using this technique

 Here,dyes stain mineralising tissues are injected in

the bone and teeth & can be later detected after
sacrificing the animal.
• Dyes :alizarin – 1936 by ‘Belchier’
Alizarin red
Acid alizarin blue
Trypton blue
Tetracycline
Lead acetate
• IMPLANT
RADIOGRAPHY:-
• 1969 by Arne Bjork.

 provides imporatant
new information about
the growth pattern

 metallic implants are

usually very tiny about
1.5mm in length.0.5mm
in diameter& are made
of tantalum
 Implant sites

• MAXILLA • MANDIBLE
 Hard palate behind primary canines  Anterior aspect of symphysis

 Below anterior nasal spine  2 pins on right side of mandibular

body

 Two implants on either sides of  One pin on external aspect of right

zygomatic process of maxilla ramus at the level of occlusal surface
of molars.
 Borders between the hard palate
medial to I molar& alveolar process
• Electromyography:
allows the action potentials of muscles of mastication to be correlated
with morphological data & normalisation of muscle function in the
treatment of malocclusion

• Natural markers:
There is a persistance of certain developmental features of bone,
which are used as natural markers.

eg : trabaculae, nutrient canals, lines of arrested growth can be used

for reference to study bone deposition, resorption ,remodeling. .
 Radio-isotopes:
• used as in vivo markers for studying bone growth

• Growth is measured by means of Geiger counters /

auto radiographic techniques.

Tc-99 detects areas of rapid bone

growth in humans.
ca-45
K -32
 BASIC TENETS OF GROWTH
• PATTERN:
means arrangement of parts, values or events.

 Clinical implication:
In Dentistry, use of word pattern has both
morphologic & developmental application.
• VARIABILITY: it is the law of nature,
because of infinite number of genetic
possibilities.

• Variability may be demonstrated in many

ways.

• In physical growth ,variability is demonstrated

by the use of statistics.
• STATISTICS:

MEAN (average of values)

MEDIAN (value midway between greatest & smallest

measurements.

MODE

STANDARD DEVIATION
• TIMING:
The timing of developmental events is largely under
genetic control yet altered by the environment.

• There are sex related differences in the timing of

many growth phenomena. usually,girls precede boys.
 DIFFERENTIAL GROWTH
• The concept of differential growth is based upon the
observation that various structures of the body
normally grow at different rates from birth to
maturity. As a result,

• each part of the body may contribute unequally to

total size attainment at different points in time
• Significant and marked differences in the rate
of growth within the same individual are
uniformly evident. The changes that occur do
not appear to be uniform and do not occur
simultaneously.
• At birth, the infant skull consists of about 45
bony elements separated by cartilage or
connective tissue. This number is reduced to
22 bones in the adult after completion of
ossification.
• Fourteen of these bones are in the face, and
the remaining eight form the cranium.
• Importance

• The practical significance of the prediction process is

to enable the dentist to predict the future facial
adolescent spurt,
• thereby enabling him to know the successful time for
orthodontic treatment.
• This is of particular significance when skeletal
discrepancy is present, a favorable growth pattern
may facilitate
SCAMMONS GROWTH CURVE
• Pattern of growth in
1.Lymphoid man – Tanner(1962)
2.Neural
3.Somatic
4.Genetic

Lymphoid tissue - rapid proliferation-200%

adult size
Neural tissue - rapid proliferation-6-7 yrs
(adult size)
• CEPHALO-CAUDAL GROWTH
CURVE :
simply means that there is an axis of increased
growth extending from head towards the feet.

a comparision of body proportion between

prenatal & post natal life reveals that post natal
growth of regions of body that are away from the
hypophysis.
 Body proportion
1.Midpoint of stature 2 • Chilander
months –chest et al(1985)
2.At birth – above the
umbilicus
3.Adult – pubic symphysis
region
4.At birth 22% of body
area is covered by head
 decreases to 13% at
12 yrs 10% in adult
 GROWTH SPURTS
• Human growth is
not a steady &
uniform process of
acceleration

• There are periods

of sudden rapid
increase,which are
termed as growth
spurts.
 Growth spurts
Name of the Female Male
spurt
Infantile / 3yrs 3 yrs
childhood growth
spurt.
Mixed dentition / 6-7 yrs 7-9 yrs
juvenile growth
spurt.
Pre-pubertal / 11-12yrs 14-15yrs
adolescent growth
spurt
a)Just before birth
• Growth in boys and
b)One year after birth
girls (modified from
c)Mixed dentition growth Bjork 1975)
spurt
 Boys- 8 -11yrs
 Girls- 7 -9 yrs
d)Adolescent growth spurt
 Boys- 14 –16 yrs
 Girls – 11- 13 yrs
• Significance of growth spurt:

1.To differentiate whether growth changes are

normal / pathologic.
2.Treatment of skeletal discrepancies ,if carried
out in mixed dentition, more advantageous
eg:appliance techniques like functional
appliances &extraoral traction
3.Orthognathic surgeries should be carried out
after the spurt.
 FUNCTIONAL APPLIANCE THERAPY IN
CONJUCYION WITH GROWTH HARMONE
TREARMENT(T.I DAVIS,P.H .W
RAYNER.JOURNAL OF ORTHODONTICS,VOL 22
1995
• The presented case is an eg :of Turners syndrome in
which affected individuals do not have pubertal
growth spurt and HGH, ethinyloestrodiol are needed
to induce the spurt. without appropriate harmone
administration it seems unlikely that a successful
orthodontic result could have been achieved,
particularly in active treatment period of 10 months.
GROWTH ASSESSMENT
PARAMETERS
• ‘KROGMAN’ defines five ages of childhood.
 Chronological age
 Biologic age
 Morphologic age
 Skeletal age
 Dental age
 Behavioural age
 Mental age
 Self-concept age
• According to singh:
Neural age
Physiological & biochemical age
Mental age
chronological age
Dental age
Sexual age
• CHRONOLOGICAL AGE:

It is defined as age measured by years lived since

birth.

it is a poor indicator of maturity as it provides little

validity for identifying the stages of development
progression through adolescence to adulthood.
• SOMATOTYPIC AGE:

 sheldon divided into 3 types

1.ectomorph – tall,thin ,fragile

2.Endomorph – stocky, abundant fat,

digestive viscera highly developed

3.Mesomorph – upright ,sturdy & athletic ,

 Growth charts
• Normal growth in children can be explained in several
ways.
1.Quantitatively
2.Qualitatively
3.Genetically determined process

• Growth charts attempt to describe these differing patterns of

growth.
• Percentile curves 
derived from a normal
distribution curve .the
median is the 50th
percentile.

 50% of population is
above & 50% of a
normal group of
children is below this
line.
• B) standard deviation charts:
based upon the scatter of observations around a mean value.
Three growth charts are available.
1.Height Vs age chart:

2.Linear growth velocity Vs age chart

3.Child height to the mid-parental height.

• Growth charts can be used to follow a child over time
to evaluate ,whether there is unexpected change in
growth pattern .

• Height has been employed as a convenient

determinant of developmental age.
Predicting adult height & weight

BOYS :2×height at 8 yrs =adult height

GIRLS :2×height at 7.5 yrs= adult

height
BOYS :5×weight at 2 yrs =adult
weight
GIRLS :5×weight at 1.5 yrs =adult
weight
 PREDICTING ADULT HEIGHT AND
WEIGHT
AGE INCREMENT HEIGHT

BIRTH - 20inches
0–6 1 inch / month 26inches
months
6 – 12 0.5 inch / month 32inches
months
1-7 3 inches / year 50inches
years
8 – 15 1 inch / year 62inches
 AGE INCREMENT WEIGHT
BIRTH - to 8 lbs

0–4 2 lbs / month 15 – 16 lbs

months
4 – 12 months 2 lbs / month 23 – 24 lbs

1–2 0.5 lbs / year 29 – 30 lbs

years
2 – 10 yrs 5 lbs / year 69 – 70 lbs
• Dental age:

the dental age is estimated by comparing the dental

development status in a person of unknown age with
published dental development surveys.
 DIFFERENT METHODS FOR
ASSSESSING DENTAL AGE
 Gron & Moore method
 Gustafson & Koch method
 Glieser & Hunter(1955):
first to advocate the calcification as a more meaningful indication
of somatic maturation than its clinical emergence.

• Demirijan:(1973):calcification of the tip of the cusp to closure of the apex

closure.
8 stages: (A – H)
0 – for no calcification.
• MENTAL AGE:
it is thus an index of maturation of mind,like
the radiological age, that depends on many intrinsic
&environmental factors.

concept of intelligence co-efficient , mental age

expressed as a percentage of chronological age
• NEURAL AGE:

helps us to understand that the patient is mentally

developed to understand the need for treatment &to
what extent could he / she would be able to co-
operate.
• PHYSIOLOGICAL AGE:
Girls show a spurt in systolic blood pressure
which occurs earlier than the corresponding spurt in
the male.

in plasma , organic phosphate shows a steady fall

from the high levels of childhood to reach adult
figures by the age of 15 in girls and 17 in boys .

A more promising index is the ratio of creatine to

creatinine.
 SEXUAL AGE
MALES:
1.accelaration of growth of the testes & scrotum.
2.appearance of pubic hair.
3.enlargement of penis
4.height spurt
5.appearance of facial & axillary hair
6.enlargement of larynx
• Females
 Appearance of breast buds & pubic hair
 broadening of hips
 Menarche, occurs almost after the maximal height.
 FACIAL AGE
• The ultimate goal of developmental growth assessment is the facial
age

 Measurements for assessing craniofacial developments are :

 Head circumference

 Eye measurements

inter canthal
inter pupillary
outer canthal

 Ear length
 philtrum length
 Width of commissures
 Change in facial proportion
 Increase in facial proportion is seen as:

 Infancy to adolescence,
 Increase in size of dental arches
 Increase in size of muscles of mastication
 Growth of alveolar process
 Increase in maxilla
 Increase in mandible
 Nasal area
 Enlargements of orbits ,
 Expansion of ethmoid &sphenoid
• NANDA Growth of the face in general tends to be
maximal slightly later than the spurt in body height.

• TOFANI Mandibular growth of females at puberty

exhibited a spurt occuring 10 months before
menarche in early maturing females.

• HUNTER 57% of maximal facial increments

occurred at the same time as maximum growth in
height
 SKELETAL AGE
• Stanecu-1977
• Basis for skeletal age assessment

• Methods to assess skeletal maturation:

1.Handwrist radiographs
2.Cervical vertebrae
3.Clinical & radiographic examination of different
stages of tooth development
 REGIONS USED FOR AGE
ASSESSMENT
HEAD & NECK SKULL , CERVICAL VERTEBRAE
UPPER LIMB SHOULDER JOINT-SCAPULA ,HAND
WRIST
LOWER LIMB FEMUR &HUMERUS
HIP JOINT,KNEE,ANKLE,FOOT-
TARSALS,PHALANGES
• ANATOMY OF
HANDWRIST:

• Distal ends of long bones of

fore arm

• Carpals
proximal
row
distal row

• Metacarpals

• phalanges
 INDICATIONS
• In patients who exhibit major discrepency between
dental & chronological age.

• Determination of skeletal maturity prior to treatment

of skeletal malocclusion

• To assess the skeletal age in a patient whose growth

is affected by infections

• To predict the pubertal growth spurt

• Valuable aid in research aimed at studying the role of

heredity, environment, nutrition
 RADIOLOGICL ASSESSMENT OF
PREDICTION OF SKELETAL
GROWTH
• Greulich & pyle method
• Bjork , grave and Brown
• Fisherman
• Singer’s assessment(1980)
• Hagg & Taranger method
• Bjork – ulna sesmoid centre as an indicator.
• Grave - pisiform , hamate, sesmoid bone
 Correlation of skeletal maturation with
pubertal growth spurt
• HAGG & PANCHERZ – at puberty the spurt in growth
in body height is accompanied by an increase in growth
rate of jaws.

• BJORK & HELM 1967 – onset of adductor sesmoid

ossification & beginning of maximum growth period.

• CHERTKOW 1980 – correlation between the growth

spurt ossification and mineralisation of lower canine
teeth.
 SKELETAL MATURATION
EVALUATION BY USING CERVICAL
VERTEBRAE MATURITY
INDICTORS

• Hassel & Farman

• Shapes of vertebral bodies of C3& C4 vertebrae
changed .
• The increasing in vertical height is associated with
increase in skeletal maturity
 RELATIONSHIP BETWEEN DENTAL
AND SKELETAL MATURITY IN
TURKISH SUBJECTS

• The appearance of each skeletal age is consistently

earlier in females than in males except for stage 9

• In Turkish subjects,tooth sequence in order of lowest

to highest correlation
• FEMALES & males
third molars

canines

first premolar

second premolar

second molar
• Findings of this study indicates that in
children of Turkish origin the completion of
roots formation of canines & first premolar
may be used as maturity indicators of
pubertal growth spurt

• It is appropriate to put these skeletal

& dental maturation relation ships into daily
orthodontic practise, when treating a Turkish
patients

(The Angle Orthodontist 74,5,2004

oct).(Tancon uysal,zafer sari et al.)
 Growth prediction
• According to Bjork:

 Longitudinal
 Metric
 structural
• Longitudinal Approach ‘Tweed’
• Type-A: growth of middle &lower face
proceeds in unison with vertical &horizontal
dimensions in being approximately equal
no treatment is indicated.
• Type-A subdivision
Type-B: middle face grows downwards &
forward more rapidly than lower face. poor
prognosis ,point B will not catch up with the
point A.
• Type-B subdivision:
• Type-C :maxilla & mandible grow forwards and
downwards with the mandible growing forwards
more rapidly than the maxilla.

• Type-C subdivision:
• This approach is accurate only when it is performed
retrospectively but not prospectively

therefore, it can be concluded that longitudinal

approach is not an accurate method of predicting
future dentofacial changes
• STRUCTURAL APPROACH:

Prediction for mandibular growth direction

Bjork.

Bjork listed seven areas on cephalograms that

should be evaluated to help predict future
mandibular growth direction.
1.inclination of condyle.
2.curvature of mandibular canal
3.iclination of symphysis
4.shape of lower border of mandible
5.inter incisal angle.
6.inter premolar / molar angles
7.Anterior lower face height
• SKIELLER,BJORK,LINDE HANSEN 
attempted to refine this prediction by
quantifying it.
• four variables:
1.ratio of posterior / anterior facial face
heights.
2.inter molar angle
3.shape of lower border of mandible
4.inclinationof symphysis
Conclusion:all the three approaches have limited
clinical value.
• METRIC APPROACH:

 Consists of measuring different structures on a single

X-ray film then relating these measurements to
future growth changes.
COMPUTERISED PREDICTION
METHODS
• The biggest advantage of computer
technology is that it facilities testing &
applying more complex formulations to
growth prediction.
• ‘Ricketts’ introduced his method of computer
analysis based on the concept of the cubic root
combined with a vast clinical experience.
• Greenberg & Johnston tested these computer
predictions.
• Comparision were made between three types
of calculations.
1.computer forecast of changes between10 & 15
yrs of age group on the 20 cases
2.the actual changes that occur in same 20 cases
3.adding the average changes of remaining 80 .
• Concluded as there were no significant
differences in accuracy between computer
prediction & those based on simple addition of
average changes.
• Cangialosi et al  computer programe using
pre treatment & post treatment cephalograms
• Growth forecast from computer is compared
with the manual method
• Computer analysis came close to the 4
variables & by manual method close to three
variables
• Predicting the skeletal & soft tissue changes
was much less accurate.
• Conclusion:

overall changes in size & relationship

of human face ,in general difficult to
accurately predict for an individual at this
time.
• because, the changes are under the
influence of combined & complex hard-to-
predict,genetic,environmental factors.the
situation is even more complex ,because we
are using two dimensional cephalograms to
evaluate a three dimensional face.
 CLINICAL IMPLICATIONS
• Inaccurate Data: Many apparent growth abnormalities
are the result of errors in the measurement of growth
parameters or errors generated when plotting growth
parameters on growth curves

• . In cases of potential growth disturbance, careful

attention to rigorous methods of measurement is:

• Children less than two years of age should be weighed

without clothing. Older children can be weighed in
lightweight clothing without shoes
• . Current assessments of growth focus heavily on the
use of growth curves developed by the National
Center for Health Statistics in the 1960s and 1970s.

• Children whose growth parameters are at the

extremes of the growth curve but who have normal
growth rates are likely to be healthy.

• Time as a Tool: Time is the primary assessment tool

available to the family physician.
• Common Pathologic Decreased weight
• Under nutrition
Etiologies of Weight
• Psychosocial
Disorders deprivation
Increased weight : • Hypothyroidism
• Endocrine disorders • Iron deficiency
• Hypothyroidism • Failure of a major organ
system
• Excess production of
• Lead intoxication
cortisol (Cushing's
disease) • HIV infection
• Thalamic or pituitary • Immune deficiencies
disorders • Zinc deficiency
• Genetic disorders • Inborn errors of
metabolism
 • Decreased height
• Growth hormone deficiency
• Common Pathologic
• Hypothyroidism
Etiologies of Height
• Chronic anemia
Disorders • (Turner's syndrome)
• Increased height : • Failure of a major organ
• Excess production of system (especially
gastrointestinal, renal,
growth hormone
pulmonary or cardiovascular)
• Hyperthyroidism
• Skeletal dysplasia/rickets
• Klinefelter's syndrome • Psychosocial deprivation
• Marfan syndrome
• Homocystinuria
 Evaluation of the patient with an
abnormal head size.
• examination and developmental status .
• Associated physical findings such as a bulging
fontanelle or split sutures, neurologic abnormalities
or delays in developmental status warrant evaluation
• Common Pathologic
Etiologies of Cranial
Disorders • Decreased head size
• Increased head size Craniosynostosis
• Hydrocephalus • Prenatal insult
• Megalencephaly • Maternal drug or
• Primary alcohol abuse
• Secondary to associated • Maternal infection
disease of the central • Complications of
nervous system such as
neurofibromatosis or pregnancy/birth
tuberous sclerosis. • Chromosome defects
• Secondary to metabolic
storage disease such as
Krabbe's disease
• The clinical implications regarding maxillo –
mandibular relation ships:

Role of growth spurts

Role of skeletal maturation
Role of direction of growth
Effect of alveolar growth on the placement
of implants.
 VARIOUS CHANGES OF DEVELOPMENT THAT ARE OF
INTEREST TO A DENTIST (5 -25YRS)

• Changes in maxillary length:

40%, 40% 20% males.
50%,30%,20% females
changes in mandibular length:
34%,39%,27% males
48%,41%,11% females.
maxillo- mandibular relationship:
• changes in various other factor
 facial type : vertical relation ship is more
pronounced.
 concept of genetic make up
 effect of environment
 conclusion
• There are least five components to be dealt with the
prediction of cranio facial changes:
 direction
 Magnitude
 Timing
 Rate of change
 Effects of treatment
• In planning & carrying out orthodontic treatment it would be
of value in predicting the final form and size of the face &
jaws. after growth has ceased.

• The prediction of skeletal height has been well documented.

• Individual variation reduces the accuracy of prediction.

• The prediction of facial form is more complex & inevitably
less accurate.
• Various growth parameters for prediction although they
received support from different investigators , there are
possibilities of measurement errors ,which limit all forecast on
growth & development, because of these dificulties, current
growth prediction are of limited value.
 REFERENCES
• Scientific foundations & clinical research –Stewart

• Handbook of orthodontics – Robert .e. moyers, iv edition

• Orthodontics –principles & practice –Graber t.m iii edition

• Orthodontics for dental students – J.H.Gardiner,B.C.Leighton, J.K.Luffingham,

Ashima valiatha

• Textbook of orthodontics – Mire.Bishara

• Textbook of orthodontics – Gurkeerat singh

• Contemporary orthodontics –Profitt,fourth edition.

• Contemporary treatment of dentofacial deformity –Profitt White
Server –south Asia Edition.
• Atlas of Advanced Orthodontics – Viazis
• Orthodontics the art & science –Bhalaji
• Textbook of pedodontics – shoba tandon
• Essentials ofpreventive & community dentistry – soben peter.III
edition.
• A Textbook of orthodontics – T.D.Foster.iii edition
• The Angle Orthodontist vol 74,5,2004 oct
• The Angle Orthodontist vol 78,1,2008 jan
• Journal Of Orthodontics,VOL 22 1995
Thank you