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CONTENTS
1. Introduction. 2. Principles of growth and development. 3. Amount and timing of growth. 4. Growth of mandible. 5. Mechanism of rotation.
b) Bjork and Skieller. c) Profitt. d) F.F. Schudy. e) Counterbalancing rotation- Dibbet. f) Enlows Concept. g) Solow & Houston. h) Solow , Siersbaek Nielsen.
11. Conclusion.
12. References.
INTRODUCTION
Development:
Is a gradual maturational process involving a complex of different but functionally interrelated organs and tissues.
The growth process also involves a succession of regional changes of great proportions and it requires countless localized adjustments to achieve proper fitting and function among all the parts.
3. Bone has periosteal and endosteal layer if one is resorbtive then other will be depository. 4. The control of growth is done by the soft tissue matrix present around the bone. The blueprint of the design construction and growth of the bone lies in the composite of muscles, tongue, lips, connective tissue, nerves, blood vessels, airways etc.
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5.
The various sites of growth do not show a same rate of growth activity. Remodeling is a basic part of growth process. Growth process leads to primary or secondary displacement.
6.
7.
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AMOUNT OF GROWTH
Timing of puberty makes a difference in ultimate body size. The earlier the puberty the smaller will be the body size.
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GROWTH OF MANDIBLE
The major parts of Mandible important for/ affecting growth rotations is:
The corpus The ramus
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Ramus is related to the pharyngeal space and middle cranial fossa, with the function being to bridge the middle cranial fossa and place the corpus in proper relation with the cranial floor articulation on one side and maxillary corpus on other side.
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Ramus undergoes continuing remodeling as a part of its growth process and several basic functions are provided by these changes:
The entire ramus gets progressively relocated posteriorly by combination of resorption and deposition. The ramus width increases to accommodate the increase in middle cranial fossa and the pharynx.
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The length of the ramus increases to accommodate the increased size of nasomaxillary complex and erupting teeth. Progressive remodeling changes occur in the ramus to place the mandibular corpus in proper relation with the maxillary corpus.
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These changes lead to change in orientation of the mandible leading to ROTATION OF THE MANDIBLE. (Rotation literally means to move round a axis or a centre.)
Types of rotations :
1.
Forward rotation
2.
Backward rotation
1965 - Schudy counterclockwise = forward clockwise = backward. 1970 - Odegard described rotation as change in the orientation that can occur between implant line and lower border of the mandible. 1977-Lavergne and Gasson described the terms Positional and Morphogenetic rotations. 1979 - Bjork and Skieller gave the terms -
Total rotation.
Matrix rotation. Intramatrix rotation
Since classic description of mandibular growth by John Hunter in 1771 there has been various studies and reports on it. He had applied anthropometry (aligned human skulls along symphyseal and lower border of mandible) to find out how mandible increased in size.
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1.
as compared to maxilla
2. 3. Convexity of Face decreased with age. Decrease in the inclination of the Mandible - less
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GROWTH ROTATIONS.
Bjork study
Started his study in 1951. Had a sample size of 100 children between the age group of 4 24 yrs. Used metal implants to find the sites of growth and resorption in individual jaws. Also examined individual variation in direction and intensity. Analyzed mechanics of changes in intermaxillary relations during growth.
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He
refuted
the
concept
that
the
given
intermaxillary relation remained static through out life. Considerable variation in the
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Direction of Growth
Mandible can have a forward direction of growth (good growing) or backward direction of growth (bad growing).
Bjork gave seven structural signs to find the direction of mandibular growth.
These signs are not clearly developed before puberty.
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Bjorks concept
Growth of the mandible occurs essentially at the condyles. The anterior aspect of the chin-stable.
The growth of the condyle occurs in a upward and forward curving manner.
The center of rotation may be located-posteriorly or anteriorly or somewhere in between. The center may not always lie at the TMJ.
FORWARD ROTATION
THREE TYPES: TYPE I
-center at the TMJ.
-underdeveloped anterior face height. -deep bite. Cause: occlusal imbalance or powerful musculature.
Type II Center at the incisal edges of the lower teeth. Marked increase in posterior facial height and normal anterior facial height. Increase in posterior face height
But this vertical lowering manifests as forward rotation muscular and ligamentous attachments.
TWO TYPES: Type I -center at the TMJ. -underdevelopment of the posterior face height occursopen bite. Causes: 1. Middle cranial fossa is raised. 2. Orthodontic bite raising appliance. 3. Oxycephaly.
BACKWARD ROTATION
TYPE II
-center at distal occluding molars. most
Cause: sagittal (backward ) growth of the condyle. -The mandible is carried forward but due to muscle and ligaments attachments its rotated backwards.
The eruption of lower molars was hinderedthe rotation not due to overeruption.
Seen in hypoplasia. condylar
Structural Signs
1. Condylar inclination. 2. Mandibular canal inclination. 3. Lower border of mandible (Antegonial notch). 4. Symphysis inclination. 5. Interincisal inclination. 6. Intermolar angle. 7. Lower face height.
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CONDYLAR INCLINATION
Forward or backward inclination of the condylar head is characteristic sign In forward growing mandible condyle is upright compared to a backward growing mandible in which it is inclined backward Is difficult to identify on the lateral cephalogram.
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MANDIBULAR CANAL
The mandibular canal curvature remains the same throughout the life. In vertical growing mandible the curvature of the canal is more than that of the mandibular contour. Where as in case of horizontal growers the canal may be flat or may even be curved in opposite direction.
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INTERINCISAL ANGLE
Interincisal angle is almost constant showing that the lower incisors is related functionally to the upper incisors In vertical growers angle in less In horizontal growers there is an increased interincisal angle.
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INTERMOLAR ANGLE
In case of forward rotation the molars get more upright increasing the intermolar and interpremolar angle while in case of backward rotation the molars become mesially tipped hence decreasing the intermolar and interpremolar angle
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Continuation
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Bjork
Schudy
General Terms . Core of the mandible . Mandibular Plane. Mandibular plane to core.
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Terminologies: Bjork
Schudy
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PROFFIT
Rotations occurring in the core of the jaw were called as INTERNAL ROTATION. Hence is the rotation which is visualized by the implant line.
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Rotation caused by the surface changes and the alteration in the rate of tooth eruption is called as EXTERNAL ROTATION. According to Profitt Rotation of the core in relation to the mandibular plane.
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Net rotation occurring due to rotation around the condyle, or rotation of mandibular plane relative to cranial base, is called as TOTAL ROTATION.
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Total Rotation
Is the rotation of the mandibular corpus Is measured as change in inclination of a reference line or a implant line in the mandibular corpus relative to the anterior cranial base. If line anteriorly rotate towards the face then is known as forward rotating and signated as -
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Matrix rotation
Is rotation of soft tissue matrix/ plane of the mandible relative to the cranial base. Is shown by a tangential mandibular line. It can rotate forward and backward in the same patient with condyles as the centre of rotation and is described by the term pendulum movement.
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Intramatrix rotation
Is the difference between total rotation and the matrix rotation. It is an expression of remodeling of the lower border of the mandible. It is found out by the change in inclination of an implant line or reference line in the mandibular corpus to the tangential mandibular line.
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Rotation of the corpus relative to the tangential line such that it faces front is called as forward rotation. Centre of rotation is somewhere in corpus and depends on rotation of corpus, growth rotation of the maxilla and occlusion of the teeth.
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Bjork and Skieller said that three changes occur in Intramatrix rotation
The mandible wiggles in in its matrix This wiggling is associated with the corpus and is caused by growing condyle. The rotation results from or compensates for genetically predetermined program.
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Angular changes change in shape - deposition + resorption - surface accretion and removal
Rotation
50% of true mandibular rotation > 50% efficiency of the counter remodelling process.
BJORK
PROFFIT
Rotation of mandibular core relative to cranial base Mandibular plane relative to cranial base
Total rotation
True rotation
Internal rotation
Matrix rotation
Apparent rotation
Total rotation
Mandibular plane Angular relative to the core Intra matrix remodeling of of the mandible
rotation
lower border
External rotation
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According to Petrovic
In orthognathic type of face the ramus and the body of the mandible are fully developed, and the width of the ascending ramus is equal to the height of the body of the mandible, including height of the alveolar process and the incisors. The condyle and coronoid process are almost in the same plane and symphysis is well developed.
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In case of a retrognathic mandible corpus is narrow in molar region. Symphysis is narrow and long, ramus is narrow and short and the gonial angle is obtuse and the coronoid process is relatively smaller than the condylar process..
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In prognathic type the corpus is well developed and wide in molar region. Symphysis is wider in sagital plane, ramus is wide and long and the gonial angle is acute or small.
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F.F. SCHUDY
Rotation of the mandible is a result of disharmony between vertical growth, anteroposterior growth and transverse growth. Clockwise rotation is a result of increased vertical growth causing a decrease in bite. Counter-clockwise rotation is a result of decreased vertical growth causing a deep bite.
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Growth increments causing downward movement of chin is called as vertical growth, while growth increments causing forward movement of chin are called as horizontal growth. If growth at the condyles is more than molar eruption it causes horizontal growth deepening the bite. If growth at the condyles is less then molar eruption is leads to vertical growth and a decreased bite.
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There are four vertical growth elements which increase the facial height, these are: Anterior growth of nasion. Corpus of maxilla getting palatal plane down. Eruption of maxillary molars. Eruption of mandibular molars.
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Edentulous experiment.
Condyle synopsis.
growth
molar
growth
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P= C- (N-ANS +Mx+Md)
In case of tipping of the palatal plate Site of First molar tooth observed.
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Morphogenetic Rotation Concerns the shape of the mandible. Superimposition done on line through condylion and pogonion. The angle formed between the 2 implant lines-degree of morphogenetic rotation. Similar to Bjorks intramatrix but not identical.
Bjork considered key factor of intramatrix to be found in a rotation of mandibular corpus inside the matrix. Lavergne and Gasson consider the forward and backward growth of the ramus the main mechanism for shortening and elongating the effective length.
The Hunterian concept or principle of Morphogenetic rotation. Superimposition based on traditional Hunterian concept of Posterior ramal deposition and Anterior ramal resorption.
Enlarging and reducing the mandibular length measured along the Co-Pog line.
COUNTERBALANCING ROTATION
The puzzle of growth rotation: Dibbets
Definition Counterbalancing rotation pertains to circular condylar growth, accompanied by selective coordinated remodeling, which does not contribute to the incremental growth of the mandible.
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Change in the inclination of the implant line relative to the mandibular plane.
This suggests1.when the mandibles are superimposed on the their contours they are identical in shape and size. 2.The condyle grows on a circular arc from the chin to condyle. (c-c) with radius
This concludes1.The external configuration need not change. 2.Any depositional-resorptive activity maintains the original contours.
The painting may be rotated within the frame but the external outline, configuration and dimensionality, of the frame is not lost.
Every deflection of condylar growth direction creates the possibility of compensatory remodeling mostly of the lower border resulting in intramatrix rotation.
concept
or
principle
of
Superimposition based on traditional Hunterian conception of Posterior ramal deposition and Anterior ramal resorption.
Enlarging and reducing the mandibular length measured along the Co-Pog line.
COUNTERBALANCING ROTATION
Intramatrix rotation capable of offsetting growth & also is capable of neutralizing growth to a substantial degree. Does so by inducing a curvilinear growth direction for Mandibular condyle , - more than is necessary to account for Mandibular enlargement + selective remodelling. - Offset condylar growth increments which can throw the Mandible out of its established equilibrium with the surrounding skeletal units. - Matrix = trigger / initiator.
COUNTERBALANCING ROTATION IS A MECHANISM THAT 1) Neutralizes growth: The actual path of the condyle relative to fixed and stable points inside the mandible is accompanied by selective remodeling. 2) Resuts in selective enlargement of the mandible, apart and distinct from mechanisms that have been described in literature.
Counterbalancing Proportion
It is the quotient between mandibular and condylar incremental growth and is expressed as a percentage. Condylar growth and mandibular growth are weighted in relation to one another. The proportion gives a percentage of condylar relocation that has contributed to actual mandibular enlargement.
Counterbalancing proportion=
x 100%
According to the concept of congruous mandibular growth the proportion should be 100%.
But study done by Dibbets shows that it ranges from 50% to 90%. This percentage strongly correlates type of malocclusion. Class III-85% Class I -76% Class II-59%
According to Profitt Contemporary Orthodontics: For an average individual with normal vertical facial proportions Age 4yrs to adult life: -15o of internal rotation (Core) 25% Matrix rotation 75% Intramatrix rotation.
Total rotation: External rotation: 2-4o 11-12o
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Core.
Contemporary Orthodontic Proffit 4th Ed.
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Implants placed on maxillary alveolar process show that the core of the maxilla undergoes a small and variable
Varying degree of resorption on nasal side and deposition on palatal side, varying amount of eruption of incisors and molars lead to EXTERNAL ROTATION.
In most individuals the external and internal rotations cancel each other.
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Total Rotation
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CLINICAL ASPECTS
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According to Lavergne and Gasson the mutual rotation of the upper and lower jaw can be of following 4 types
1. Convergent rotation.
Severe deep bite.
2.
Maxillary
rotation.
cranial
rotation
CLINICAL ASPECTS
1. Growth rotation of mandible influence the amount the teeth can erupt.
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3.
Normal internal rotation rotates mandible forward uprighting the incisors and allowing the molars to mesialize.
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4. Normally the forward rotation of the maxilla is less then that of mandible causing the mandibular arch length to decrease.
Hence in brachyfacial individuals crowding tends to be more, since the mandibular incisors tend to retrocline more, decreasing the arch length.
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According to Profitt
Eruption of mandibular upward and forward teeth
According to Update on the Wits Appraisal By Alex Jacobson The Angle Orthodontist July 1988.
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Treatment Aspects
According to Pepicelli in his AJODO 2005 The mandibular muscles and their importance in orthodontics: A contemporary review
The more extreme the rotation of the mandible, during growth in either direction, the greater the clinical problem for the clinician.
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Extrusive Mechanics
Most orthodontic mechanics are extrusive, and this extrusion appears to maintain or even increase the vertical dimension during orthodontic treatment. Undesirable molar extrusion more in Dolicofacial pattern. During treatment, extrusive forces with such mechanics as intermaxillary elastics or particular headgears should probably be avoided in patients with backward-rotating tendencies to try to limit, as much as possible,any undesirable backward rotation of the mandible.
The mandibular muscles and their importance in orthodontics: A contemporary review Pepicilli AJODO 2005
Extractions
Earlier concept. Current concept. Reasons: - Extrusion of posterior teeth and growth. - Treatment timing: For Brachyfacial Late mixed dentition stage. Dolicofacial patients: Adolesence.
The mandibular muscles and their importance in orthodontics: A contemporary review Pepicilli AJODO 2005 131
According to Proffit the general rule to follow is extrusion done more easily post surgically whereas intrusion must be handled presurgically or during surgery.
If facial height is short and distance from the incisal edge to chin is normal Extrusion of posteriors to move the chin downwards during surgery. If lower incisors elongated and face height normal/ excessive - Intrusion of molars.
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In short face, deep bite individuals prior to surgery teeth are aligned Anteroposterior positioning of the teeth is established excessive spee left. Extra thickness of splint on premolar area. Post surgical leveling.
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Surgical Considerations
Class II Skeletal pattern with deep bite and HGP.
Post surgical extrusion enhances surgical increase in LFH. Overcoming of heavy bite force pre-surgically.
The mandibular muscles and their importance in orthodontics: A contemporary review Pepicilli AJODO 2005 134
Muscular Anchorage
The teeth would be controlled with natural anchorage in a brachyfacial pattern, where the musculature is strong, but there would be less muscular anchorage in dolichofacial subjects with weak mandibular musculature. Hence in case of vertical growers the occlusal forces on the molars are less hence is more easy to loose anchorage, while in horizontal growers it is difficult to loose anchorage. Weaker musculature would be less able to overcome the molar-extruding and bite-opening effects of orthodontic treatment.
The mandibular muscles and their importance in orthodontics: A contemporary review Pepicilli AJODO 2005 135
Retention
Brachyfacial patients may protrusive and proclined dolichofacial patients. tolerate incisors more than
The mandibular muscles and their importance in orthodontics: A contemporary review Pepicilli AJODO 2005 136
Functional appliances lead to opening of mandibular plane angle hence are contraindicated in cases of vertical growers. Cases with an VGP & open bite prior to treatment were unsuccessful However according to Patel in his article in the Angle orthodontist, Cephalometric Determinants of Successful Functional Appliance Therapy 2002. Of 72 patients those with pretreatment differences being smaller and more retrusive mandible with smaller anterior and posterior face heights had higher success rates of myofunctional appliance therapy.
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Tongue thrust & differences in clinical manifestations in Horizontal and vertical growth rotations.
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RME
According to previous immediately after expansion, there is downward maxillary displacement and extrusion of the supporting teeth, leading to downward and backward mandibular rotation. The opening rotation of the mandible induces cephalometric changes, such as increases in inclination of the mandibular plane, in lower anterior facial height, and in facial convexity, in addition to evident bite opening in the anterior region. However according to this article of study on 25 patients end results not significant.
Longitudinal Effects of Rapid Maxillary Expansion A Retrospective Cephalometric Study. Garib DG Angle orthodontist 2007
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Molar consideration:
Distalisation
Conclusion
Growth rotation though a general topic has far reaching effects clinically be it in patient diagnosis, treatment planning or treatment delivery. Hence the understanding of this subject is essential in our field for a more wholesome treatment approach and understanding.
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References
1. Contemporary Orthodontics 4th Ed William R Profitt. 2. Dentofacial Orthopedics with Functional Appliances 2nd Ed Graber Rakosi Petrovic. 3. Essentials of facial growth D.H. Enlow. 4. Handbook of orthodontics R.E. Moyers. 5. Prediction of mandibular growth rotation A. Bjork, AJO, June 1969, pg. 585-599. 6. The puzzle of growth rotation J.M.H. Dibbets, AJO, June 1985, pg. 473-480.
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7.
Mandibular rotations: Concepts and terminology. Solow and W.J.B. Houston, EJO 1988 pg. 177-179. 8. Normal and abnormal growth of the mandible. A synthesis of longitudnal cephalometric implant studies over a period of 25 years. Bjork, Skieller. EJO 1983 pg. 1-46. 9. Prediction of mandibular growth rotation evaluated from a longitudinal implant sample Bjork, Skieller and Hansen. AJO Nov 1984, pg. 359-370. 10. Some effects of mandibular growth on the dental occlusion and profile R.J. Isaacson et.al. AO April 1977 pg. 97-106.
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11. Growth pattern of mandible : some reflections. B. G. Sarnat, AJO, Sept 1986, pg.221-231. 12. The Rotation Of The Mandible Resulting From Growth: Its Implications In Orthodontic Treatment - F. F. Schudy, AO, 1965, pg-36-50. 13. Physiologic timing of orthodontic treatment J. Singer, AO Oct 1980, pg. 322-333. 14. Prediction of mandibular growth rotation: Assessment of the Skieller, Bjrk, and Linde-Hansen method. Am J Orthod Dentofacial Orthop 1998;114:659-67. 15. Association between Bjorks Structural Signs of mandibular Growth Rotation and Skeletofacial Morphology Bremena; Pancherz. Angle Orthod 2005;75:506509.
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16. Mandibular Rotation And Enlargement. Dibbets Am J Orthod Dentofac Orthop 1990;98:29-32.
17. Mandibular rotation and lower facial height indicators.Ghafari. Angle orthodontist. 18. Prediction of mandibular growth rotation. Bjork. AJODO 1969.
19. The mandibular muscles and their importance in orthodontics: A contemporary review Pepicilli AJODO 2005. 20. Longitudinal Effects of Rapid Maxillary Expansion A Retrospective Cephalometric Study. Garib DG Angle orthodontist 2007 21. Update on the Wits Appraisal By Alex Jacobson The Angle Orthodontist July 1988. 22. Cephalometric Determinants of Successful Functional Appliance Therapy. Patel et al Angle Orthodontist 2002.
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