Growth and development nasomaxillary complex/ dental implant courses

GROWTH ANDGROWTH AND
DEVELOPMENT OFDEVELOPMENT OF
NASOMAXILLARYNASOMAXILLARY
COMPLEXCOMPLEX
www.indiandentalacademy.comwww.indiandentalacademy.com

• Introduction.
• Anatomy of maxilla.
• Articulations of maxilla.
• Growth of naso-maxillary complex.
• Mechanism of growth.
• Remodeling changes in specific areas of
naso-maxillary complex.
• Maxillary height
• Maxillary width
• Maxillary length
• Growth rotations of the maxilla.
• Summary.
• Bibliography. www.indiandentalacademy.comwww.indiandentalacademy.com

GROWTH OF THEGROWTH OF THE
NASOMAXILLARY COMPLEXNASOMAXILLARY COMPLEX
The maxilla is a paired bone i.e.
two maxilla join to form a
maxillae.
It is surrounded by and
articulates with various
bones that influence its
growth pattern.
Hence, growth of maxilla is
studied as the growth of
naso-maxillary complex.www.indiandentalacademy.comwww.indiandentalacademy.com

MaxillaMaxilla
MAXILLA - cheek in Latin
The largest facial bone except mandible

ANATOMY OF MAXILLAANATOMY OF MAXILLA
• It consists of:
i.) Body
ii.) Four Processes:
• Frontal process.
• Zygomatic process.
• Horizontal Palatine
Process.
• Alveolar Process.

1. BODY: Hollow.
Roughly pyramidal.
Encloses the maxillary sinus.
• 4 Surfaces:
a.) Anterior. c.) Orbital.
b.) Infra-temporal. d.) Nasal.
• Anterior Surface:
Parts:
Incisive fossa.
Canine fossa.
Infra-orbital foramen.

• Infra-temporal Surface:
• Concave .
• Faces postero-laterally.
• Forms anterior wall of infra-temporal fossa.
• Separated from anterior surface by zygomatic
process.
• It presents: Foramina of alveolar canal.
Maxillary tuberosity.

• Orbital Surface:
Smooth and triangular.
Forms the orbital floor.
• Nasal Surface:
Forms greater part of lateral wall of nasal cavity.
It displays following structures:
Maxillary Hiatus.
Inferior meatus.
Greater Palatine Canal.
Naso-lacrimal Duct.
Oblique conchal crest.

• MAXILLARY SINUS
A large pyramidal cavity.
• Walls: Orbital wall.
Alveolar wall.
Facial wall.
Infra-temporal wall.
• Parts:
• Apex: Lies laterally and is
truncated.
• Extends into
zygomatic process.
• Base: Lies medially.
• Forms lateral wall of
nasal cavity.

• PROCESSES OF MAXILLA:
Zygomatic Process:
Pyramidal projection
where anterior, infra-temporal
and orbital surfaces converge.
Frontal Process:
Projects postero-
superiorly between the nasal
and lacrimal bones.
Alveolar Process:
Thick and arched.
Provides socket to
tooth roots. www.indiandentalacademy.comwww.indiandentalacademy.com

ARTICULATIONS OF MAXILLAARTICULATIONS OF MAXILLA
i.) Cranial:
Frontal.
Ethmoid.
ii.) Facial:
Nasal.
Lacrimal.
Inferior nasal
concha.
Vomer.
Zygomatic.
Palatine.
Opposite maxilla.

PRENATALPRENATAL
DEVELOPMENT:DEVELOPMENT:
• Around the fourth week of intra-uterine life, a
prominent bulge appears on the ventral aspect
of the embryo corresponding to the developing
brain.
• This bulge is termed as Frontal prominence.
• Below this bulge , a shallow depression
corresponding to the primitive mouth appears,
called Stomodeum.

• The stomodeum
consists of:
• i.) Oral groove.
• ii.) Maxillary
processes.
• iii.) Mandibular arch.

The floor of the stomodeum is formed by the
Buccopharyngeal membrane that separates it from
the foregut.
At about 27th
day of intra-uterine life, this membrane
ruptures and the primitive oral cavity establishes a
connection with the foregut.

The mesoderm covering
the developing brain
proliferates and forms
a downward
projection that
overlaps the upper
part of the
stomodeum. This
downward projection
is called the
Frontonasal Process.

• Now, local thickenings
develop within the
ectoderm of the frontal
process. These
thickenings are the
Nasal Placodes.
• These placodes
eventually give rise to
lining of the nasal pits,
and the olfactory
epithelium

• During the fifth week ,
the olfactory placodes
are bordered by
rapidly growing horse
shoe shaped
elevations. The
medial aspects of the
elevations are the
medial nasal
processes and the
lateral limbs are the
lateral nasal
processes.

• Thus after five weeks, the
structures that border the
upper aspect of the oral
cavity are:
• i.) The frontal prominence
in the midline.
• ii.) The paired processes
on either side of the
frontal area.
• iii.) Paired maxillary
process at the upper
lateral angles.

FORMATION OF PHILTRUMFORMATION OF PHILTRUM
The medionasal process grows downward more
rapidly than the lateral nasal processes and
ultimately by the sixth week to eighth week fuse
on their lateral aspect with the maxillary process
and with the other medio-nasal process at the
same time.

The fusion gives rise to the central depression of the upperThe fusion gives rise to the central depression of the upper
lip called thelip called the Philtrum.Philtrum.
I
Medial Nasal Process
Lateral nasal Process
Developing Maxilla
Odontogenic Epithelium
Developing Mandible
II Hyoid arch
Frontonasal Process
Developed Philtrum

FORMATION OF PRIMARY PALATEFORMATION OF PRIMARY PALATE
The deeper portions of these tissues form the dental tissues i.e.
dental arch, premaxillary area carrying the incisor teeth and
the palate. These structures which represent a single unit are
called Primary Palate.
By the eighth week, facial structures are apparent. Nose is
more prominent and the nasal septum elongates and
becomes narrow. Eyes and ears are developing. Nostrils are
formed by an opening in the nasal pits . Nasal septum forms
from the cells of medionasal and frontal process.

DEVELOPMENT OF PALATEDEVELOPMENT OF PALATE
• i.) Each maxillary
process contributes a
palatal shelf; and the
pre-maxilla region
develops from the
medial nasal process.

• ii.) The lateral palatine shelves, which are vertically
oriented in the initial phases, fuse together and assume
a more horizontal position above the tongue around the
seventh week.
• iii.) The palatal shelves which are covered by the
epithelium, fuse with each other and with the pre-
maxillary portion of the palate around eight and half
weeks.

POST NATAL GROWTH OF NASO-POST NATAL GROWTH OF NASO-
MAXILLARY COMPLEXMAXILLARY COMPLEX
(Graber)(Graber)
• There is no sharp line of demarcation
between cranial & maxillary growth
gradients
• Two phenomenon-
• Shift in position of maxillary complex
• Enlargement of complex

The nasomaxilary complex, other than the
nasal septum grows by intramembranous
bone formation. The nasal septum grows
by endochondral bone formation.

MECHANISM OF GROWTHMECHANISM OF GROWTH
i.) Sutural growth
ii.) Growth of the cartilaginous nasal septum
iii.) Appositional growth as well as modeling resorption on
the surfaces of bones.
iv.) By secondary growth of maxilla due to growth in the
cranial base
v.) Role of functional matrices in the growth of
nasomaxillary complex.

SUTURAL GROWTHSUTURAL GROWTH
The sutural theory for bone growth was given by
Weinmann & Sicher in 1955.
In the maxillary region, there are four main suture
sites.
a.) Frontomaxillary suture.
b.) Zygomaticomaxillary suture.
c.) Zygomaticotemporal suture.
d.) Pterygopalatine suture.
Another suture which is of significant importance is
the mid palatine suture.

a.) Frontomaxillary
suture.
b.) Zygomaticomaxillary
suture.
c.) Zygomaticotemporal
suture.
d.) Pterygopalatine
suture

These sutures are
essentially parallel to
each other and all face
from an antero-superior
to a postero-inferior
direction thus growth in
the sutures causes the
downward and forward
movement of the
maxillary complex.

• Lacrimal suture – key growth mediator (Enlow Hans)
• Lacrimal bone is a flake of bony island surrounded by
sutural connective tissue contacts – ‘perilacrimal
sutural system’
• Without this adjustive development a GRIDLOCK
would occur among multiple developing parts
• It’s a developmental hub providing ‘key traffic
controls’

• The increment of bone growth in the sutures exactly
equals the amount of inferior displacement of the
whole maxilla .This is primary DISPLACEMANT
because it take place in conjunction with its own
enlargement
• Multidirectional mode of primary displacement &
differential extents of bone growth causes a slide or
slippage of bones ALONG the plane of interface is
involved

• Bjork (1951) conducted a study on the sutural system of
growth of maxilla by the implant method using small metal pins
as implants. His sample included 130 children of both sexes
representing both normal craniofacial growth and selected
cases of pathological growth.
• The implants were placed in four regions:
• i.) At early juvenile ages, before the permanent incisors had
erupted, near the median plane of the face in the hard palate
behind deciduous canines.
• ii.) After the eruption of permanent central incisors, they were
inserted below the anterior nasal spine on each side of median
suture and on a level with the root apices but not in contact with
them.
• iii.) Zygomatic process of the maxilla.
• iv.) Border of hard palate and alveolar process medial to the
first molar ( Krebs,1961)

• Results:
• In order to study this the first and last radiographs were
compared by superimposing them so that the maximum
number of structures in the anterior cranial fossa and pterygo-
palatine fossa coincided.
• One line was placed through nasion and sella points on the
first radiograph, another through implant region(1) or region
(2) on the first and second radiograph
( respectively).
The angle between these lines has been taken as a general
expression of the direction of sutural growth of the upper
face in the sagittal plane.
The mean angle for 37 boys was given as 51 with the error of
+/-5 but it varied individually from almost purely sagittal to
purely vertical.

Rate of Sutural Growth:
i.) Juvenile period:
Is an average of 1mm.
ii.)Prepubertal minimum :
Growth is 0.25 mm.
iii.) Pubertal maximum:
1.5mm/ year.
iv.) Cessation of growth:
At 17yrs. Of age.

Sutures and forces - Wagemans, van deSutures and forces - Wagemans, van de
Velde, and Kuijpers-Jagtman(1998 AJO-Velde, and Kuijpers-Jagtman(1998 AJO-
DO )DO )
• Article gives a review of the knowledge of sutural
tissue response to extrinsic mechanical forces.
• RESPONSE OF SUTURES TO FORCES IN
VITRO Weed, Hall, and Johnson demonstrated
an in vitro increase in mice calvarial cell binding
capacity to areas containing certain
noncollagenous proteins, like gelatin and
fibronectin.

• Fibronectin is an extracellular matrix- and cell
surface-associated glycoprotein that
accumulates in site-specific patterns during
embryogenesis.It accompanies differentiation
of the osteoprogenitor cells

• TRANSPLANTATION EXPERIMENTS
• The natural environment of a suture is changed.
• New position-nonfunctional (nongrowing) site or may
become exposed to altered mechanical factors.
• Nonfunctional site- eg transplanting the suture into a
fenestra in a bone or implantation of the suture into
the brain.
• In most studies the suture initially showed continuous
growth at the edges. Sometimes, premature
synostosis was observed.www.indiandentalacademy.comwww.indiandentalacademy.com

• Prahl observed that growth in the implant continued
and concluded that the suture possesses a high
autonomous growth potential.
• In a recent study, (Nash and Kokich)-atrophic
changes in sutures transplanted to nonfunctional
sites, 50% of the transplants showed bony fusion
across the sutural space.
• In general, however, bone formation was decreased.
It was concluded that elimination of normal
biomechanical stresses and immobilization lead to
atrophic degeneration of the connective tissue of
transplanted sutures and to premature loss of
osteogenic activity

• Transplanted into another sutural region growth
generally is adaptive to the new site.
• Engdahl, Ritsilä, and Uddströmer transplanted the
coronal suture of young rabbits into a defect in the
premaxillary-maxillary suture. With vital staining, it
became evident that the growth rate of the
transplanted coronal suture far exceeded that of a
control coronal suture and was as fast as that of a
normal premaxillary-maxillary suture

• Sutural morphology does not always adapt to its
new environment.
• Engdahl, Ritsilä and Uddströmer observed that
the coronal suture did not become as tortuous
as the premaxillary maxillary suture after
transplantation. Therefore, the coronal suture
seems to be less adaptive than the sagittal
suture

• In a clinical study, Isaacson and Ingram
quantified force magnitude during rapid
expansion with a forcemeasuring dynamometer.
• Forces produced by an expansion screw caused
accumulated loads more than twice as large as
the original force.
• Because the force value did not decrease when
the midpalatal suture opened, they concluded
that the expansion is counteracted by the entire
craniofacial complex

RESPONSE OF SUTURES TO EXTRINSICRESPONSE OF SUTURES TO EXTRINSIC
MECHANICAL FORCES IN VIVOMECHANICAL FORCES IN VIVO
• Direct force application to a single suture.
• Ten Cate, Freeman, and Dickinson exerted an
expansion force with a spring on the sagittal suture
of adult rats.
• The maximal opening of the suture was 2 mm.
• An immediate response of traumatic tears, exudate,
death of fibroblasts, disruption of collagen fibers, and
acute inflammation was observed
• visible at the electron microscopic level.
• Within 3 to 4 days, bone formation was observed at
the edges of the suture, together with collagen
deposition and remodeling of fibroblasts.www.indiandentalacademy.comwww.indiandentalacademy.com

• Ten Cate, Freeman, and Dickinson noticed that the
first bone, which was formed 3 to 4 days after force
application, was laid down in lamellae along the
sutural edges.
• Debbane applied expansion forces to the palatal
suture of full-grown cats. Woven bone was
deposited perpendicular to the matrix of existing
bone. Deposition in the suture was unevenly
distributed.
• Conclusion- sutural response to direct or indirect
force application can be divided into different stages
1.An initial traumatic response followed by a period
of connective tissue repair.

2.New bone is deposited perpendicular or
parallel to the edges of the suture in
tension areas, while bone resorption
takes place in areas of compression.

• Bone deposition at the bony edges takes place in
order to reestablish the original morphology
• Long-term effects
• Storey compared the effects of rapid maxillary
expansion with slow maxillary expansion in rabbits.
After rapid expansion the suture was disrupted and
interdigitations were lost.
• Even after 6 weeks of retention, relapse of the bones
was observed.
• After slow expansion, however, the sutural integrity
had been maintained and consequently the rate of
relapse was reduced

CARTILAGINOUS NASAL SEPTUM GROWTHCARTILAGINOUS NASAL SEPTUM GROWTH
Scott in early 1950s postulated that the
cartilaginous nasal septum is primarily
responsible for the translation of the facial
bones, permitting growth of the mid-facial region
to proceed in a downward and forward direction
by the mechanism of surface deposition of new
bone matrix.
The septal cartilage was presumed to act as a
pacemaker which regulates midfacial growth till
the eruption of the deciduous dentition is
completed

• He assumed that intrinsic growth controlling factors
were present only in cartilage & in periosteum
• He claimed that growth in the sutures was secondary
& entirely dependent on the growth of cartilage &
adjacent soft tissues
• Not all investigators support this theory. According to
Moss and Bromberg , the growth of midfacial region
is independent of the septal cartilage and latter
simply grows as a compensatory response to oro-
facial matrices.

• Research was done by Ohyama on rats
• Resection of septum by using delicate &
atraumatic procedures
• Findings: nasal septum is a primary growth
center for nasal, frontal, premaxillary & maxillary
bones
• In cleft palate: maxillary growth has been
retarded where as nasal septum continues to
grow & even bends on itself into the
characteristic “S” shape.

SECONDARY DISPLACEMENT OF MAXILLASECONDARY DISPLACEMENT OF MAXILLA
The maxilla is intimately
related to the anterior
cranial base.
Growth of surrounding soft
tissues translates maxilla
in downward & forward
direction
.

• The movement of bone & soft tissues is not
directly related to its own enlargement
• Eg – the anterior direction of growth by middle
cranial fossae & the temporal lobes of cerebrum
SECONDARILY displaces the entire
nasomaxillary complex anteriorly & inferiorly
• Called the ‘domino effect’ that is growth
changes can be passed on from region to region
to produce a secondary effect in areas quite
diatant
• Such effects are cumulative

Functional cranial analysisFunctional cranial analysis
• (Moss based on theory by Van der Klaauw) The
head is a composite structure consisting of
independent functions
• Each function is carried out by a group of soft
tissues which are supported &/0r protected by
related skeletal elements- functional cranial
component.
• Totality of all skeletal elements associated with
the single function is termed as skeletal unit
• Totality of soft tissues associated with the singlewww.indiandentalacademy.comwww.indiandentalacademy.com

• This theory explains ‘what’ happens but not ‘how’
• Facial bones are passively carried outward
(downward, forward and laterally) by primary
expansion of enclosed orofacial matrices (orbital,
nasal, oral matrices)
• In addition there is essential growth of sinuses and
spaces. The resultant maxillary changes in the
skeletal elements would thus be secondary,
compensatory and mechanically obligatory.
• Eg growth of orbital floor so that orbital cavity is not
unduly enlarged

• Another important functional matrix in the orofacial
region is the teeth.
• As the teeth erupt, there is an increase in height of
the maxillary complex by the continued apposition of
the alveolar bone on the free borders of the alveolar
process.

• Moss cites 3 types of bone growth change in maxilla
• Changes associated with compensation for passive
motions of bone brought about by primary expansion
of orofacial capsule
• Changes in bone morphology associated with
alterations in absolute size ,volume , shape , or
spatial position of any or all maxillary functional
matrices
• Bone changes associated with maintenance of form
of bone( Enlow)

REMODELLINGREMODELLING
The overall growth changes in the maxilla are the result
of both a downward and forward translation of the
maxilla and a simultaneous surface remodeling.
The whole bony nasomaxillary complex is moving
downward and forward relative to the cranium, being
translated in space.

Cortical drift by Enlow 1963Cortical drift by Enlow 1963
• The cortical plate can be relocated
by simultaneous apposition &
resorption process on the
periosteal & endosteal surface the
bone. Cortical plate drift by
depositing & resorbing bone
substance on the outer & inner
surface respectively, in the
direction of growth

• It is not necessary that the remodeling
changes oppose the direction of translation.
• Depending on the specific location, translation
and remodeling may either oppose each other
or produce an additive effect.

• The effect is additive on
the roof of mouth.
• This area is carried
downward and forward
along with rest of the
maxilla , but at the same
time, bone is removed
on the nasal side and
added to the oral side
thus creating an
additional downward and
forward movement of the
palate. www.indiandentalacademy.comwww.indiandentalacademy.com

ENLOW’S ILLUSTRATION SHOWINGENLOW’S ILLUSTRATION SHOWING
MAXILLARY BONE REMODELLINGMAXILLARY BONE REMODELLING
• The anterior part of the
alveolar process is a
resorptive area so removal
of bone from the surface
here tends to cancel some
of the forward growth that
otherwise would occur
because of translation of
the entire maxilla.

Maxillary heightMaxillary height
• Continued
apposition of
alveolar bone on
free borders of
alveolar process as
teeth erupt (40 % of
total maxillary
height increase till
late adoloscence) –
vertical drift

Bony apposition on orbital floorBony apposition on orbital floor

• Concomitant
resorption on nasal
floor
• Apposition of bone
on inferior palatal
surface

• Implant studies by Bjork & Skieller
Maxillary height increases by sutural
growth toward frontal & zygomatic bones
& appositional growth in alveolar process

• Major change in surface
occurs along vertical
crest just below malar
protuberance – “ key
ridge”
• A reversal occurs here
• External surface of
maxillary arch is
resorptive , provides an
inferior direction of arch
growth along with
downward growth of
palate

• The combination of
resorption of the superior
side of the palate &
deposition on the inferior
(oral side) produces the
down ward growth
movement of palate .
This relocate it
inferiorly ,a process that
provide for vertical
enlargement of the
overlying nasal region.

Maxillary widthMaxillary width
• Palatal growth
follows the ‘principle
of the expanding V’
(Enlow1965)
• Areas grow by bone
resorption on outer
surface of the V and
bone deposition on
the inner side.

• The V moves away
from its tip &enlarges
simultaneously
• Additive growth on
free ends increases
distance between
them

• Functional matrix concepts of Moss
explains stimulus with compensatory
changes at mid palatal suture
(questionable if midpalatal growth is
primary motivating force)
• Enlow shows appositional growth on
lateral walls of maxilla

Maxillary lengthMaxillary length
• Apposition on maxillary tuberosity
• Depository field in which backward facing
periosteal surface of tuberosity receives
deposits of new bone
• Endosteal surface of cortex within tuberosity
(maxillary sinus ) is resorptive
• Thus cortex relocates posteriorly & to lesser
extent laterally
• Maxillary sinus increases in size
• Major site of maxillary lengthening

• Lobret confirmed minimal change in shape
of top of palatal vault with only alveolar
process increasing in height & breadth
continuously
• Growth in width is completed first
• Growth in length
• Finally growth in height

• Growth in width of jaw including the dental arches
tends to be completed before the adoloscent growth
spurt & is minimally affected by adolescent growth
changes.
• Because of maxilla's intimate contact with cranial base
& because of the possibility of the endocrinal
dominance over membranous bony changes there
are number of observers who believe that the maxilla
width follows neural growth which is completed quite
early.

• Growth in length & height of jaw continues through
the period a definitive of puberty.
• Downward & forward maxillary growth which follows
the general growth curve& continues to parallel
pubertal changes .
• In both the sexes growth in vertical height of face
continues longer than growth in length.
• Greatest increase is seen in maxillary height followed
by depth and least in width.

Maxillary growth patternMaxillary growth pattern
• Zygomatic region:
• As the maxilla lengthens by new growth on its
posterior margins, the zygomatic process moves
posteriorly and laterally.

i.) The lateral &i.) The lateral &
posterior is additive.posterior is additive.
ii.) Anterior & medialii.) Anterior & medial
surface is resorptivesurface is resorptive

iii.) So, the zygomatic process moves in two
directions: Posteriorly Laterally.
iv.) Both the inferior and superior surfaces
are characteristically depository.

• Premaxillary Region:
i.) The labial cortex is composed mainly of endosteal bone. This indicates that the
periosteal surface is resorptive.
ii.) Periosteal surface of lingual cortex is depository so, both cortical plates move in a
lingual direction.

• Nasal Area:
• The nasal area is composed of the frontal
process of the maxilla and the adjacent nasal
bone. It is oriented such that its external
surfaces face laterally, superiorly and anteriorly.
• Since, growth progresses in this direction, these
surfaces are characteristically depository and
the cortex is composed entirely of periosteal
bone.

• Surface accretion on the
outer side of nasal wall
moves the whole nasal area
anteriorly.
• This, along with the
downward movement of the
maxillary region, contributes
to the protruding nose:
characteristic of the human
face.
• Surface deposition on the
lateral surface of nose
produces widening of the
nasal bridge. www.indiandentalacademy.comwww.indiandentalacademy.com

OrbitalFloor:The orbital floor is formed mainly of the
maxillary bone. It faces laterally, superiorly and
anteriorly. Periosteal deposition causes the bone to
move in the same directions.

MAXILLARY SINUSMAXILLARY SINUS
The maxillary sinus grows at the expense of the bones of the
nasomaxillary complex. Hence, during its own growth, it
influences the growth of this complex.
LOCATION OF MAXILLARY SINUS IN MAXILLA

GROWTH ROTATIONS OF THE MAXILLAGROWTH ROTATIONS OF THE MAXILLA
Bjork,1960s; carried out implant studies on the rotations of the
jaws during growth. Two types of rotations are:
a.) Internal Rotations. b.) External rotations.
• After placing implants above the maxillary alveolar process, it
was observed that a core of the maxilla undergoes a small and
variable degree of rotation.
• The internal rotation of the maxilla occurs and also occurs
varying degrees of resorption of bone on the nasal side and
apposition of bone on the palatal side, in the anterior and
posterior parts of the palate.
.

• Variations also occur in the amount of eruptions of incisors
and molars.
These changes amount to external rotation
• For most of the patients, external rotation is opposite in
direction and equal in magnitude to the internal rotation, so
that the two rotations cancel and the net change in jaw
orientation is zero.

Growth increments for maxilla:
1.) 0-5yrs. : 45% of total growth.
2.) 5-10yrs. : 25% completed.
3.) 10-20yrs.: Rest 35% completed
growth of maxilla completed till late
adolescence.. Around 18-20 yrs.

SUMMARYSUMMARY
• Maxilla is not a single bone entity. It is surrounded by
and articulates with various bones which play a
significant role in its growth.
• The naso-maxillary complex grows predominantly by
intra-membranous bone formation .
• The growth of nasomaxillary complex is attributed
mainly to secondary displacement of maxilla, sutural
growth, growth of cartilagenous nasal septum,
appositional growth and remodelling; and finally the
functional cranial components.
• Any disturbances during growth pre-natally or post-
natally may lead to descrepancies in growth of maxilla.

BIBLIOGRAPHY
• Proffit William R. : Contemporary Orthodontics,ed.3,
2006, C.V . Mosby, 39; 65; 70 134-136.
• .Enlow DH: Handbook of facial growth, 3rd Ed. , Philadelphia
1990 W.B. Saunders Company, pg.42,49-51,83-84,87.
• Graber T.M :Orthodontics Principles And Practice, Third ed.,
Philadelphia 1996, W.B. Saunders Company, 48-63,68,69,71
• Enlow DH, Hans MG: Essentials of Facial Growth,
W.B. Saunders, ed. 3, 1996, Philadelphia, 25-34; 115; 118;
139-142.
• Ten Cate AR: Oral Histology, ed.3, 1989, C.V Mosby, 30-35.

• Bishara Sameer E. , Text book of Orthodontics,W.B.
Saunders, 2001, 202;226.
• Wagemans, van de Velde, and Kuijpers-Jagtman: Sutures and
forces- AJO DO Volume 94,NO 2: Aug1988 (129 - 141):
• Grant’s Atlas of Anatomy, ed.9, Williams and Wilkins,
Baltimore, 463.
• Bjork A : Prediction of mandibular growth rotation. Am. J
Orthodont1969, 55;589-599
• Robert E Moyers, Handbook Of Orthodontics,4th
edition,1973,57-60

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