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Anchorage in Orthodontics

Anchorage in Orthodontics

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04/02/2013

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Sections

• Defination
• Classification
• Manner of force application
• Stationary Anchorage
• Reciprocal Anchorage
• Egs of Reciprocal Anchorage
• Site of anchorage
• According to jaws involved
• Begg & PEA
• Palatal Bar
• The Nance holding arch
• Lingual arch
• Lip Bumper
• Vertical anchorage control

● Concept ● Definition & Classification ● Consideration of anchorage in three planes of space ● Anchorage planning (Methods to increase anchorage potential) ● Tweeds concept of anchorage preparation ● Anchorage considerations with Begg ● Anchorage considerations with PEA ● Anchorage demand- minimum, moderate , maximum ● Implants as a source of anchorage

● Whenever a force is applied the stabilized site from where the force is exerted is the anchorage ● Tug of war● Two equal sized people will pull each other together by an equal amount. ● A big person will pull a small one without being moved. ● If two or more smaller person combine the chances of pulling a big person will increase.

.● The pegs/ stakes driven into the ground at an angle to support the tent ● The stakes are at an angle that the pull of the tent ropes against the stake would not increase 90˚ ● The stakes driven too vertically will be pulled upward & towards the tent.

● Newton & his laws of motion: ● Law I: A thing at rest or in motion continues to do so unless acted upon by an external force ● Law III : Every action has an equal & opposite reaction .

The force (F) will have to overcome the frictional force( Fr) bw the body (b) & the surface (S). ● For eg. we must have a force acting on the body. Lets apply a force (F) to move it to the left. the gravitational force (G). Body (B) is at rest. .● We know that to create movement / displacement. ● If the force (F) is smaller in magnitude than the sum (Fr+G). only then a particular movement will be seen. then no movement will take place.

below which that particular movement cannot be produced. ● So this force level is the anchorage potential of the body (B) for that particular movement .● For every kind of movement there exist an optimal force level.

● Let us now come to oral cavity & teeth. 100 gm. the force applied to the canine is approx. ● Forces in the opp. . direction varying from 67 gm on the 1st molar to 33gm on the upper 2nd PM resist this. ● Minimum unwanted anterior movement of the posterior teeth. with bodily movement using a fixed appliance. ● If an upper canine is to be retracted.

● As the force level is increased to 300g the reciprocal forces also increases with greater risk of mesial movt. . of post teeth.

● The anchorage value of any tooth is roughly equivalent to its root surface area .

& to dissipate the reaction force to as many other teeth as possible.Relationship of tooth movt. keeping the pressure in pdl of anchor teeth as low as possible. . To force ● An obvious strategy for anchorage control is to concentrate the force needed to produce tooth movt where it is desired.

● Pressure in Pdl is determined by f/a. & then may actually decline with extremely heavy pressure. remains at the same level up to a broader range. ● Tooth movt increases as pressure increases up to a point. .

● The optimum force for orthodontic tooth movement is the lightest force that produces a maximum or near maximum response (i. ● Forces greater than that . which brings pressure in the PDL to the edge of the nearly constant portion of the response curve). would be unnecessarily traumatic & stressful to the anchorage . though equally effective in producing tooth movement.e.

● Let us consider the response of anchor teeth (A) & teeth to be moved (M) in three circumstances. where as the pressure in anchor unit is suboptimal --Anchor teeth moved less . ● In each case. the pressure for the teeth to be moved is optimal. ● In the first case(A1-M1). the pressure in the Pdl of (A) is less than that of (M) because there are more teeth in the anchor unit.

. Although this is theoretic & may not be encountered clinically. the anchor teeth might move more than the teeth it was desired to move. ● With extremely high force(A3-M3).● In the second case(A2-M2). The anchor teeth can be expected to move as much as the teeth that are desired to be moved. both are on the plateau of the pressure response curve.

Defination ● The term Anchorage in orthodontics refers to the nature & degree of resistance to displacement offered by an anatomic unit when used for the purpose of effecting tooth movement .

According to manner of force application ● 2.Classification ● 1. To jaws involved ● 3. Based on site of anchorage ● 4. Based on no. Acc. . of anchorage units.

Stationary Anchorage ● 3. Simple Anchorage ● 2. Reciprocal Anchorage .Manner of force application ● I.

Simple Anchorage ● Dental anchorage in which manner & application of force tends to change the axial inclination of the tooth or teeth that form the anchorage unit in the plane of space in which the force is being applied. . ● Resistance of the anchorage unit to tipping is utilized to move another tooth or teeth.

of roots ● Shape.Factors important for assessing resistance value of an anchorage unit( tooth) ● The part of tooth which is anchored in the alveolar bone ● No. size & length of each root– A triangular shaped root offers greater resistance to movement than a conical or ovoid shaped root .

A is more resistant to displacement than one with a smaller R.Or it can also be expressed as the approximate root surface area.A Other factors are also involved such as -.Relation of contiguous teeth -.S.S.the forces of occlusion --The age of pt --individual tissue response variables . A tooth with a larger R.

● Amt. of post. teeth while serving light forces against the ant. The forces should be below the threshold needed for movt. teeth.● It is also imp. to check inclined plane relationships & muscular forces in assessing value of an anchorage unit. . of force used is also imp.

Is considerably greater than one resisting tipping force .● Dental anchorage which manner & application of StationaryinAnchorage bodily in force tends to displace the anchorage unit the plane of space in which the force is being applied is termed Stationary anchorage. ● Anchorage provided by a tooth which is resisting bodily movt.

If the appliance were arranged so that the anterior teeth could tip lingualy while the posterior teeth could only move bodily. of teeth against tipping of another. .● This refers to the advantage that can be obtained by pitting bodily movement of one gp. ● For eg. so these teeth would move ½ as much. the optimum pressure for the anterior segment would be produced by abt. ● This would mean that the reaction over the post teeth would be reduced by ½. 1/2 as much force as if the anterior would be to be retracted bodily.

direction. forces tends to move each unit towards a more normal occlusion. . of teeth of equal anchorage value are made to move in opp.Reciprocal Anchorage ● Refers to resistance offered by two malposed units when the dissipation of equal & opp. ● Two teeth or two gp.

Egs of Reciprocal Anchorage .

● classification…… Site of anchorage ● Intraoral Anchorage ● Teeth ● Alveolar bone ● Basal bone ● musculature ● Extra oral Anchorage ● Cranium (occipital or parietal anchorage) ● Back of neck (Cervical anchorage ● Facial bones .

● classification…… According to jaws involved ● Intramaxillary Anchorage ● All the resistance units are situated in the same jaw .

● Also termed Baker’s anchorage .● Intermaxillary Anchorage ● Anchorage in which resistance units situated in one jaw are used to effect tooth movement in the opposing jaw.

Class II intermaxillary elastics Class III intermaxillary elastics .

of anchorage units ● Single or primary anchorage ● Cases wherein the resistance provided by a single tooth with greater alveolar support is used to move another tooth with less support .● classification… … Based on no.

● Compound Anchorage ● Here the resistance provided by more than one tooth with greater support is used to move teeth with lesser support .

extraoral forces ● -.adding 2nd molars to the post unit to augment post achorage ● --Traspalatal arch .Multiple / Reinforced Anchorage ● More than one type of resistance unit is utilized ● Refers to augmentation of anchorage by various means ● -.

.Three Dimensional Anchorage evaluation ● Considering anchorage in all the three planes (sagittal. vertical & transverse) ● And subsequent anchorage planning is very important before initiating any tooth movements.

Of post. Segment while encouraging distal movt. . Of ant.● Horizontal anchorage control means limiting the mesial movt. division 1 case" is one in which no forward movement of the upper posterior segments is allowed. a "maximum anchorage Class II. but preparation is made for maximum retraction of the upper anterior segment. Segments. ● For example.

Segment. . Segments & the limitation of the vertical eruption or even intrusion of the ant.● Vertical anchorage control involves limitation of the vertical skeletal & dental development in the post.

● In the transverse plane. . it comprises of maintenance of expansion procedures & the avoidance of tipping or extrusion of posterior teeth during expansion.

ANCHORAGE PLANNING Methods to increase anchorage potential ● I . By increasing the resistance to displacement ● II. By decreasing the displacement potential .

in the absence of brackets a rigid sectional arch wire can be bonded to the teeth. teeth are connected by rigid sectional arch wire(18×25. to create a buccal segment which acts like a large multirooted tooth generating good post. 19×25). of teeth in the anchorage ● 1. Increase the unit ( increase root surface area) ● 2. .Alternatively. anchorage.Increasing the resistance to displacement no.Create Buccal segments The post.

. Cortical anchorage ● Moving the roots of anchor molar into the cortex increases their resistance to displacement. ● Incorporation of anterior vault of palate enhances post. ● 3..Increasing the resistance to displacement…. ● 4. Anchorage. lingual arches . Nance’s button ● The bilateral buccal segments thus connected offer significant benefits. Palatal .

Increasing the resistance to displacement… ● 5. Extraoral anchorage ● 6. Muscular forces can be used to augment anchorage such as through use of lip bumper .

Implants. These create distal tipping forces. Moments generated through cantilever springs or base intrusion arches are applied to anchor teeth.Increasing the resistance to displacement… ● 7. ● 8. Ankylosed teeth ● They are perfect egs of stationary anchorage . which help to resist anterior displacement of anchor units.

Reduce friction ● 3.movt. Reduce forces .Decreasing the displacement potential ● 1. Reduce forces ● 2.using movements which require less force .. Sequential loading ● 1. In stages ● ..

● 2. Reduce friction ..Decreasing the displacement potential….002 clearance is advocated for using sliding mechanics ● … Optimal leveling to reduce binding effect ● 3. Sequential loading …Gradual progression towards stiffer slot filling arch wires .use of optimal clearance bw bracket & arch wire.. Using frictionless mechanics ● . 0.

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. ● It is mainly limited o high cuspid. crossbite pseudo-Class III. and true Class III cases.Tweed’s Classification of ● First Degree Anchorage preparation anchorage ● It is applicable to all malocclusions with ANB angles ranging from 0˚ to 4˚ in which facial esthetics are good and in which total discrepancy does not exceed 10 mm.

● Mandibular terminal molars must always be uprighted and / or maintained in such an upright position as to prevent their being elongated when Class II intermaxillary force is used .● The degree to which anchorage should be prepared is minimal.

.● As a general rule. this means that the inclination of the mandibular terminal molars should be such that the direction of pull of the intermaxillary elastic force during function will not exceed 90˚ when related to the long axis to these teeth.

● These cases are usually Class II in nature and require prolonged Class II intermaxillary mechanics .5˚and facial esthetics make it desirable to move point B anteriorly and point A posteriorly ●.● Second degree anchorage preparation ● Indicated when ANB exceeds 4.

.● They are accompanied by Type A. Type B and Type B subdivision growth trends ● The mandibular terminal molars must be tipped distally so that their distal marginal ridges are at gum level. Type A Subdivision.

● The direction of pull of the Class II elastics when related to the long axes of the terminal molars should be greater than 90˚ during function. so that the terminal molars will be further depressed rather than elongated .

. ● Jigs are necessary for third degree or total anchorage preparation in the mandibular arch.● Third degree or total anchorage preparation ● It is necessary in extremely severe malocclusion in which total discrepancy vary from 14 to 20 mm or more but the ANB angle does not exceed 5˚ ● Class I in nature. with exceedingly irregular teeth.

● In these all three posterior teeth from and including the second PM’s to and including the terminal molars must be tipped distally to anchorage preparation positions ● This means that both second PM’s and first molars must be tipped to such distoaxial inclinations that the distal marginal ridges of the terminal second molars are below gum level .

during the period when prolonged and vigorous intermaxillary force is being used . their mesial displacement & elongation will not be great.● In such positions.

● Conventionally Begg technique is considered to be kind on to the anchorage & the PEA anchorage taxing .

Begg base PEA & arch wire ● Pinning of into anteriors generates powerful posterior anchorage by activating the anchor bend ● Simultaneous aligning. each with its anchorage considerations. leveling & retraction of U/L anteriors Anchorage is to be actively created Discreet phases of aligning Levelling /& retraction of U/L anteriors. .

tipping & with torque control uprighting which is which places strain kind to the anchorage onto the anchorage Anteriors have the ● No MD tipping freedom to tip in both freedom LL but importantly mesiodistally. Are 2 stages.Movts of ant. . are in ● Movt of ant.

● Loosing anchorage is a definite & positive decision ● Conserving anchorage is a definite & positive decision .

Because of the features built in the appliance. . which tend to procline the teeth ● Let us examine diff. phases of treatment.Anchorage considerations with PEA ● Anchorage control in PEA is very imp. & how the anchorage can be controlled.

. so that leveling and aligning is achieved without key features of the malocclusion becoming worse".● McLAUGHLIN & BENNETT ● Defined anchorage control during leveling and aligning as "the maneuvers used to restrict undesirable changes during the initial phase of treatment.

Control of anchorage in the horizontal plane ● Anchorage control in the ant segment ● Anchorage control in the post segment .

.Anchorage control in the ant segment In initial wires with preadjusted system. tip built into anterior brackets increases tendency of anterior teeth to tip forward.

& there was a tendency for the anterior teeth to tip and rotate distally. usually with elastic forces.Early attempts were made to minimize tipping by connecting the anterior and posterior segments. increasing . But this created a greater demand for anchorage control.

010 or .1.009 ligature wires which extend from most distally banded bracket to the canine bracket. Lacebacks For A-P canine control ● These are . .

.They restrict canines from tipping forward during leveling & aligning. In extraction cases. these prevented cuspid tipping & are an effective means of distalizing the canines without the unwanted tipping.

in contrast. .I moved 1mm distally. ½ of which were treated with lace backs & ½ without.● Robinson investigated 57 PM Xn cases.4 mm. the L. with lace backs in place.I moved forward 1. ● His findings confirm that Lower canine lace backs have beneficial effect in controlling lower incisor proclination. ● Without lace backs. the L.

.2. Bend backs for A-P incisor control Bending the arch wire behind the most distally banded molar also minimizes forward tipping of incisors.

& where A-P control is not required.● Like lacebacks. bendbacks are continued throughout leveling & aligning archwire sequence. ● In cases where it is necessary to increase arch length. bendbacks should be placed1 or 2 mm distal to molar tubes. .

● Headgear ● Palatal Bar ● Lingual arch ● Lip Bumper ● Class III elastics . maintained in their position or even distalized.Anchorage control in the post segment ● In certain cases. it may be necessary for the upper post segments to be limited in their mesial movt.

● Extra oral force is most effective method of post anchorage control in U arch.

● Anchorage reinforcement in vertical and anteroposterior plane in extraction cases with critical anchorage requirement

According to the direction, extra oral assemblies can be grouped into:

(a) cervical – anchorage obtained from the nape of the neck (b) occipital – anchorage obtained from back of the head (c) parietal – the upper part of the back of the head is used as anchorage

High pull Cervical pull .

as in cervical traction.● If the LF passes below the CR of the tooth. ● If it passes above the CR of the tooth then intrusive component of force will be present. an extrusive component of force will be present. .

While simultaneously allowing effective distalization of the molar .● The combination headgear is useful in most cases. ● It minimizes the tendency for extrusion of upper posterior teeth.

It is soldered to the molar bands. .Palatal Bar ● Anchorage control – ● Constructed of heavy .045 or .051 inch (1.1 or 1.3 mm) round wire extending from molar to molar with a loop placed in the middle of the palate& the wire abt 2mm from the roof of the palate.

The Nance molars to the anterior portion of holding arch ● It extends from upper the palatal vault. ● A steep anterior palatal vault has a buttressing effect so is a useful source of anchorage .

of the lower molars & ensures that most of the Xn space is available for anterior alignment Lingual arch .● Used as space maintainers ● Used for max anchorage PM Xn cases ● It restricts the mesial movt.

● It transmits the lip pressure on the lower molars & support the post anchorage. Lip Bumper .

Muscular Anchorage .

where more anchorage support is needed that can be provided by a lingual arch alone. Class III elastics can be worn to Kobayashi tiewires in the lower canine region. at the same time as a head gear. ClassIII Elastics & headgear .● In cases with severe lower incisor crowding.

the incisors may be entirely bypassed. Vertical anchorage control . ● It is important to avoid early archwire engagement of high labial canines. to prevent deepening of the bite anteriorly.● In case of distally tipped canines. till the canines are uprighted. so that unwanted vertical movement of laterals & PM does not occur.

to minimize extrusion of these teeth.● Vertical control of molars in high angle cases ● Upper 2 molars are usually not initially banded. If they reqire banding an arch wire step can be placed behind the 1st molar to avoid extrusion nd .

they are designed to lie away from the palate by approx 2mm so that tongue can exert an intrusive force. U/ L post bite plate in molar region is helpful to minimize extrusion of molars.● If palatal bars are used. ● In some cases. . Cervical pull HG is avoided. ● Combination pull or high pull headgears are used.

. is essentially a transpalatal arch with an acrylic pad. ● The VHA uses tongue pressure to reduce the vertical dentoalveolar development of maxillary permanent first molars.● VHA.

040-inch chrome cobalt wire with a dime-size acrylic button at the sagittal and vertical level of the gingival margin of the molar bands. . ● Four helices were incorporated into the wire configuration for flexibility.● The VHA was fabricated with banded maxillary permanent first molars connected with a 0.

● AJO 2000. ● Evaluation of the vertical holding appliance in treatment of high-angle patients ● Marcsss DeBerardinis.● VHA restricts and even helps to reduce the percentage of lower anterior vertical face height. Oklahoma City. and Ram S. Nanda. Tony Stretesky. volume 117 . Pramod Sinha. Okla.

.Anchorage control in transverse plane ● Inter canine width ● Maintenance of intercanine width is important for stability. ● Molar crossbites ● They should be corrected by bodily movt. Rather than tipping which extrudes the palatal cusps. They should be kept as close as possible to the starting dimensions.

Horizontal plane (anteroposterior) ● A Control of anterior segments Lacebacks Bendbacks ● B Control of posterior segments Upper arch Headgears Transpalatal arch Nance holding arch Summary .1.

Lower arch Lingual arch Class III elastics Lip bumper .

Vertical plane A Incisor control ● Avoid engaging the incisor when the canines have negative angulations.2. ● Utility arches B Molar control ● Upper second molar banding to be avoided initially (in high angle cases). .

● Transpalatal arch should be 2-3 mm away from the palate. ● Posterior bite planes or bite blocks . ● High pull or combi pull headgear to be used.● Expansion if required should be achieved by bodily movement of the posterior teeth (in high angle cases).

3. B Correction of molar crossbite ● Rapid maxillary expander. . Lateral or transverse plane A Maintenance of upper and lower intercanine width. ● Quad helix ● Transpalatal arch.

● ANCHORAGE CLASSIFICATION ● Anchorage needs of an individual treatment plan could vary from absolutely no mesial movement of the molars/ premolars permitted (or even distal movement of the molars needed) to 100% of the space closure by mesial protraction of the posterior teeth Anchorage can be classified as: Retraction or space closure .

A Anchorage. This category describes the critical maintenance of the posterior tooth position. Seventy-five percent or more of the extraction space is needed for anterior retraction B Anchorage This category describes relatively symmetric space closure with equal movement of the posterior and anterior teeth to close the space. This is the least difficult space closure problem

C Anchorage This category describes non critical anchorage. Seventy-five percent or more of the space closure is achieved through mesial movement of the posterior teeth. This could also be considered to be critical anterior anchorage .

COMPONENTS OF FORCE SYSTEM ● Alpha Moment ● This is the moment acting on the anterior teeth (often termed anterior torque). ● Beta Moment ● This is the moment acting on the posterior teeth Tip-back bends places mesial to the molars produce an increased beta moment .

. The distal force acting on the anterior teeth always equal the mesial forces acting on the posterior teeth.● Horizontal Forces ● These are the mesio distal forces acting on the teeth.

● Vertical Forces ● There are intrusive-extrusive forces acting on the anterior or posterior teeth. if alpha moment is greater than the beta moment. ● The magnitude of the vertical forces is dependent on the difference between the moments and the interbracket distance. These forces generally result unequal alpha and beta moments. then extrusive forces act on the anterior teeth while intrusive forces act on the posterior teeth. . ● When the beta moments is greater than the alpha moments. an intrusive forces acts on the anterior teeth.

.● Symmetric Space Closure – Group B Anchorage ● The requirement for space closure include equal translation of the anterior and posterior segments into the extraction space. Equal and opposite moments and forces are indicated. ● A T-loop spring centered between the anterior (canine) and posterior (molar) attachments produces this force system.

● Maximum Posterior Anchorage – Group A Space Closure ● The biomechanical paradigm for this space closure problem is to increase the posterior M/F ratio (beta M/F ratio) relative to the anterior M/F ratio (alpha M/F ratio). the T-loop is positioned closer to the posterior attachment or the molar tube. a vertical intrusive force acts on the anterior segment. . ● Utilizing the V-bend principle. The beta moment is greater than the alpha moment.

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The alpha (anterior) moment is increased relative to the beta (posterior) moment. The difficulty results from this extrusive force. thus deepening the overbite. ● The primary side effect is an extrusive force acting on the anterior teeth. .● Maximum Anterior Anchorage – Group C Space Closure ● The biomechanical principle reverses the approach to Group A space closure.

otherwise. the spring is positioned closer to the anterior segment. the play within the brackets reduces the effectiveness of the moment differential. It is important that the anterior wire segment achieve full bracket engagement.In Group C space closure with a segmented Tloop. .

Implants as a source of anchorage ● In contemporary orthodontics Implants is the best source of anchorage. ● The pioneering studies on oral implants was done by LINKOW who is rightfully called the Father of Oral Implantology . which doesn’t rely on patient compliance.

● Implants can be used for Space Closure.● Implants are defined as alloplastic devices which are surgically inserted into or onto the jaw boneBoucher. They are used in the retromolar region to move teeth distally or anteriorly for mesial movement .

● Skeletal Anchorage System ● (For open bite correction) ● Sugawara.115) ● They developed skeletal anchorage system using Titanium plates as a source of anchorage for intruding the molars. Umemori et al (AJO 1999. ● The implants used are ‘L’ shaped Titanium implants. .

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● A mucoperiosteal flap is raised in the apical region of the 1st or 2nd molar and the cortical bone is exposed. with long arm exposed to the oral cavity.● Surgical Procedure ● Done under LA. ● The ‘L’ shaped miniplate is adjusted to fit the contour of the cortical bone and fixed to the bone by using screws. .

● After wound healing occurs and elastic force was applied from molar to the miniplate for intrusion . . ● Lingual crown torque was applied in the lingual arch to prevent the buccal flaring as the molar intrudes and after the treatment the miniplates are removed.

● Skeletal Anchorage System ● (For deep bite correction) ● Creekmore;Eklund et al, the possibility of skeletal anchorage (JCO 1983;17) ● They inserted a surgical vitallium bone screw just below anterior nasal spine. ● Ten days after the screw was placed,a light elastic thread was tied from the head of the screw to the archwire

● The elastic thread was renewed throughout treatment,so that a continous force was maintained 24 hrs a day. ● After 1 year they found that the maxillary CI were elevated 6mms and torqued lingually about 25 degrees.

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● MiniImplant:● Ryuzo kanomi.2mm in diameter ● 6mm in length .(JCO 1997. ● Minimplant-1.31) ● The author used an implant made of miniscrews to fix the bone plates. Miniimplant for orthodontic anchorage .

.Placement of mini-implant.

Inc.).Taken from the JCO on CD-ROM (Copyright © 1997 JCO. Volume 1997 Nov(763 767 .

.Placement of mini-implants for cuspid retraction.

Placement of mini-implants for molar intrusion. .

so always use kind action forces to have kind reactions forces on the anchorage.Conclusion ● It is very important to plan anchorage right before hand so as to have a smooth progression on to a predetermined optimal end result. . ● Kind action always invoke kind reactions.

1988 2. Pramod Sinha. WB Saunders. and Ram S.Mosby year book inc. Tony Stretesky. Graber T. Sr Louis.1994 5. AJO 2000. Profitt WR: Contemporary Orthodontics. volume 117 .inc.M: Orthodontics: & Practice.References Principles 1. Nanda.Year book medical publishers.1988 4. Robert L Vanarsdall: Orthodontics current principles& techniques. Robert E Moyers: Handbook of Orthodontics. Evaluation of the vertical holding appliance in treatment of high-angle patients Marcs DeBerardinis.1986 3. CV Mosby. Thomas M Graber.

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