Uses of head gears in growing skeletal class /certified fixed orthodontic courses by Indian dental academy


Published on

The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit ,or call

Published in: Education, Technology, Business

Uses of head gears in growing skeletal class /certified fixed orthodontic courses by Indian dental academy

  1. 1. Uses of Head gears in Growing Skeletal Class II patients.
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. Introduction: • Every orthodontic correction has to be fully integrated into both the facial type and the growth pattern of the patient being treated. • By being aware of the patient's facial type, we can make the best possible appraisal of his growth trend and project our treatment into this scheme, choosing the appliances suitable to the therapeutic objectives.
  4. 4. Characteristic features of Skeletal class II patients. Skeletal Class II malocclusion may be characterized by both sagittal and vertical discrepancies: Sagittal discrepancies: a) Prognathic maxilla and orthognathic mandible. ( maxillary protrusion.) b) Retrognathic mandible and orthognathic maxilla. (mandibular retrusion.) or c) a combination of both.
  5. 5. Maxillary protrusion. Mandibular retrusion. Combination of both.
  6. 6. • Vertical discrepancies depend upon the rotation of the mandible in respect to a site of rotation: • A) Forward rotation: Three types. • Type I: About centers in the joints resulting in deep bite. • Type II: About the centers at the incisal edges of the lower anterior teeth due to the combination of marked development of posterior face ht. and normal increase in the anterior ht. resulting in normal development. • Type III: About the centers at the premolars resulting in the decreased anterior facial ht. and basal deep bites.
  7. 7. Class II malocclusion due to forward and upward rotation of the mandible.
  8. 8. • Backward rotation: Less common. Two types. • Type I: About the centers in the joint resulting in open bite and increased anterior facial height. Mandible is normal. • Type II: About the centers at the most distal occluding molars resulting in open bites.
  9. 9. Class II malocclusion due to downward and backward rotation of the mandible.
  10. 10. • In Skeletal class II malocclusion with prognathic maxilla, the anteriorly placed maxillary base can be tipped upward or downward. • If the palatal plane is tipped upward anteriorly, it accentuates the maxillary prognathism. • A palatal plane that is tipped downward anteriorly reduces it. Downward or upward tipping of the maxilla.
  11. 11. + • In a cephalometric study (McNamara, 1981), – Mandibular skeletal retrusion with deep bite was the most common. – A wide variation in vertical development, with onethird to one-half the sample having increased vertical facial dimensions. – The anteroposterior position of the maxilla was, on average, neutral, with far more cases of maxillary skeletal retrusion than maxillary skeletal protrusion being observed.
  12. 12. Favourable and Unfavourable Growth pattern. • Skeletal class II base, deep bite, high mandibular plane angle with vertical growth potential is unfavourable • Skeletal class II base , deep bite, low mandibular plane angle with horizontal growth is favourable for class II sagittal correction but is most unfavourable for overbite correction. • Skeletal class II base, open bite, high mandibular plane angle with vertical growth potential is unfavourable.
  13. 13. AJO, June 1969. • According to Bjork, the more extreme the rotation of the mandible during growth, the greater the problems. • In case of pronounced forward rotation, there is a major risk of deep bite developing. • In case of backward rotation, opening the bite is difficult to prevent.
  14. 14. Parts of Head gear. • • • • • Facebows Head caps/Neck straps Safety modules Head gear tubes and Fly tubes
  15. 15. Facebows
  16. 16. Standard Facebows:
  17. 17. 1.14 mm 1.83 mm • Various color codes. • Standard and mini length outer bow. TP orthodontics. • With/without inner bow hooks.
  18. 18.
  19. 19. Inner bows: GAC international.
  20. 20. Inner bow bends: • U loop bend: • Allows adjustments in the inner bow for desired arch lengths by closing the loops. • Bayonet bend: • Allows the inner bow to be seated without impinging on the bicuspid teeth or retraction springs.
  21. 21. Outer bows: GAC international.
  22. 22. GAC international.
  23. 23. GAC international.
  24. 24. J-hooks: • Two separate curved gauze wires(.072”) that are formed on their ends into small hooks • Used only with the fixed appliance. The midpoint between most anterior and posterior teeth is considered as center of resistance. • This is more commonly used for retraction of canines or incisors rather than orthopedic purposes. •Available as a pair. •Available in small and large sizes.
  25. 25. Head caps/Neck straps
  26. 26. TP orthodontics.
  27. 27. TP orthodontics.
  28. 28. TP orthodontics.
  29. 29. Safety modules
  30. 30. •Available in various colours. •Available in various force magnitudes: 350 gf – light. 500 gf – medium. 750 gf – heavy.
  31. 31. Headgear tubes
  32. 32.
  33. 33. Advantages: (Worms ct. al. -1973). • Ease of control • Better access and • Better hygiene. Disadvantages: • Away from the center of resistance as a result more moment is created.
  34. 34.
  35. 35. Advantages: • Close to the center of resistance therefore line of force close to it. Disadvantages: • Poor oral hygiene and • Poor accessibility
  36. 36.
  37. 37.
  38. 38. Fly tubes: “Flying tubes” are incorporated independently in the base plate.
  39. 39. Biomechanics of Head gears.
  40. 40. Center of resistance of various units. • The center of resistance of a single-rooted tooth is generally assumed to be .4h, where h is the amount of root covered with bone. • Force passing through the center of resistance can cause pure translation and any other force will produce translation and rotation with the movement.
  41. 41. Center of resistance of an individual molar tooth.
  42. 42. Center of resistance of a segment.
  43. 43. The center of resistance of a fully bonded arch lies between the premolar roots.
  44. 44. Centers of resistance in mid facial complex 1. Alveolar process. 2. 2. Maxilla. The center of resistance of the nasomaxillary complex is somewhere in the area of the posterosuperior aspect of the zygomaticomaxillary suture.
  45. 45.
  46. 46. • Lowering the outer facebow enhances the tipping effect, thus increasing anterior overbite and reducing posterior facial height. • Vertical control is crucial because it dictates the final position of the chin in the profile. • This effect should be avoided in brachyfacial cases, but can be used to advantage in mesofacial or dolichofacial types with tendencies to anterior open bite.
  47. 47. • When the outer facebow is bent upward, both the occlusal and palatal planes are rotated counterclockwise. • anterior intrusion and normal molar eruption result in an improvement of anterior deep bite and an increase in posterior facial height. • Forward movement of the mandible is inhibited, despite the effect of the activator. Such an effect is indicated in brachyfacial patients with anterior deep bite and short lower facial height .
  48. 48. • When the direction of force passes between the two centers of resistance, there is a slight clockwise rotation of the palatal plane and a counterclockwise rotation of the occlusal plane,. • The facial axis remains unchanged or closes slightly, allowing complete freedom of mandibular growth. • Indicated in moderate deep bite and mesofacial or slightly dolichofacial patterns
  49. 49. Direction of the force.
  50. 50. Cureton1992 JCO Nov • The direction of force of a headgear at the center of resistance of a tooth or group of teeth can be accurately assessed by projecting a profile slide of the patient over a cephalometric tracing. This allows the clinician to adjust the headgear as necessary until the desired force system is obtained.
  51. 51. Lateral cephalogram taken with headgear in place; stainless steel wires taped to headgear straps show lines of force. Profile photograph of same patient. Profile slide of patient wearing headgear projected over cephalometric tracing.
  52. 52. Duration of the force. • Atleast 12 to 14 hrs per day (Klein 1957, Rickets 1960). • Recommended in the evenings- growth hormone release is higher. Growth hormone enhances the new bone formation at the epiphyseal plates of the long bones in growing children.
  53. 53. Force: • Heavy • Light • Intermittent • Continuous
  54. 54. Heavy - Intermittent forces. • Less damage to the teeth and periodontium, minimal tooth movement. • Helps in growth modification at sutural areas by preventing the amount of separation that would have occurred during growth. • Stimulus for the resorption is diluted.
  55. 55. Magnitude of the force. • For dental movements -15 to 400gms per side depending on the size and tooth movement. • A minimum force of 250 gm per side (total 500gm) is enough for to modify skeletal change. • To maximize the potential for skeletal change, orthopedic force – 400 to 900 gm per side [ 1 to 2 pounds ] (Graber 1965).
  56. 56. • Analysing the force system. Magnitude of moment of force = Magnitude of force x perpendicular distance from the center of resistance to the line of force. • Thus for a given force the greater the distance from the CR that the force is applied, the greater will be the moment.
  57. 57. Timing of force application • Orthopedic effect – in growing children • Most active period of growth – - Just before the eruption of permanent teeth or in mixed dentition. - During the pubertal growth spurt
  58. 58. Cervical pull headgear. • Point of attachment lies below the occlusal plane ,the external force is directed inferiorly as well as posteriorly. • With the face bow the cervical attachment permits the creation of force vector that permits the extrusive and distal movement of molars. • Force vector is altered when the angle of the face-bow in relation to the dental bow and the length of the face-bow are changed.
  59. 59. (A)Long arm, resultant line of force passes distal and apical to centre of resistance - distal root tipping. CERVICAL PULL (B) Short arm, resultant line of force passes mesial and occlusal to centre of resistance - mesial root tipping.
  60. 60.
  61. 61. High pull headgear. • Point of attachment is above the occlusal plane • The extra oral force is directed superiorly and posteriorly • High attachment permits the force vector to correct anteroposterior maxillary excess and vertical maxillary excess. • Force vector is altered when vertical position of the outer bow is changed.
  62. 62. (C) Long arm, resultant line of force passes distal and occlusal to centre of resistance – mesial root tipping. OCCIPITAL PULL (D) Short arm, resultant line of force passes mesial and apical to centre of resistance distal root tipping.
  63. 63.
  64. 64. Straight pull headgear • External force is directed to more surface area – more comfort. • Direction of the force vector can be modified. • If the forces are equal for each attachment the resulting force vector is usually above the occlusal plane but inferior to the vector created with the occipital attachment alone. • Requires more patient co operation
  65. 65. Clinical applications of Head gears in Skeletal Class II patients.
  66. 66. The sagittal correction of Class II cases may be brought in several ways: • Relocating the maxilla backward or inhibiting its growth, • Moving the upper teeth distally, • Releasing forward growth of the mandible, • Moving the lower teeth mesially, • Inhibiting the vertical growth of the maxilla,and • Inhibiting eruption of upper posterior teeth while permitting eruption of lower posterior teeth.
  67. 67. Low angle cases. The treatment objectives in cases of this nature are to: • reposition the maxilla posteriorly, • permit forward growth of the mandible, • promote eruption of lower posterior teeth, • promote extrusion of the upper molars and distal eruption of the remaining upper posterior teeth, • restrain the anterior vertical growth and eruption of teeth, and • prevent mesial drift of lower posterior teeth and buccal tipping of lower incisors.
  68. 68. • Extra oral force is mandatory for 2 reasons: • There is an extensive skeletal discrepancy due essentially to a protracted maxilla and, • The lower incisors would not be tipped further labially, which happens often when activator are used alone. • Extraoral appliance of choice - Cervical headgear, since it has both a distal and an inferior force component.
  69. 69. Cervical Pull Headgear.
  70. 70. • The long outer bows - 15 degrees above the inner bow to facilitate extrusion and prevent any distal tipping of the anchor molars. • The sagittal correction will be achieved mostly by a posterior repositioning of the upper arch and teeth and, to some extent, by the natural forward growth of the mandible. • The ramal growth compensates for eruption of molars and horizontal growth contributes to move the mandible forward
  71. 71. • Outer bow is adjusted such that the headgear force line of action passes through the units center of resistance. • Effects: Extrusive component, distal component, and no moment.
  72. 72. • In treating short-face Class II maxillary protrusive cases with low mandibular plane angles and deep bites, where it is desirable to extrude the upper posterior teeth. • Long outer bow • Outer bow is adjusted high such that the headgear force line of action passes distal to the units center of resistance • Effects: Extrusive component, distal force component, and moment that tends to flatten the occlusal plane
  73. 73. • Outer bow is low and short. • Effects: Extrusive component, distal component, Large moment steepens the occlusal plane. • The clockwise moment produced with this headgear is very effective in helping conserve anchorage in extraction cases.
  74. 74. Average angle cases. • Class II children with normal face height (many of whom have anterior deep bite because of excessive eruption of lower incisors) can be treated with either headgear or a functional appliance, • If molars are moved distally and extruded, the mandibular plane angle tends to increase. • Straight-pull or Interlandi headgear is preferred over cervical headgear, to reduce elongation of maxillary molars and better control
  75. 75. Straight pull headgear
  76. 76. • It is a combination of the high-pull and cervical headgear. • Main advantage is pure posterior translatory force as required in Class II malocclusion with no vertical problems. • This is accomplished by placing the force vector through the center of resistance, parallel to the occlusal plane. • This means bending the outer bow to the same level as CR, and hooking the elastic to a notch at the same vertical level. This prevents anterior migration of maxillary teeth, or possibly even translate them posteriorly.
  77. 77. • Combination of occipital and cervical pull • Short outer bow angulated at high. • Net force’s line of action passes through the center of resistance • No moment • Pure distal force • Used typically for redirecting maxillary horizontal growth ,distal translation of maxillary molar
  78. 78. High angle cases. A) High angle with open bite -Treatment objectives are to : • • • • • • inhibit vertical and sagittal growth of the maxilla, prevent further eruption of the upper molars or, even better, intrude the upper molars, promote sagittal growth of the mandible through reorientation of physiologic muscle forces, prevent eruption of the lower molars, move the lower teeth mesially, and promote vertical growth of the anterior alveolar bone and eruption of incisors by removing any possible muscle interferences.
  79. 79. •The extraoral appliance of choice is the occipital high-pull headgear since we want (1) to inhibit sagittal and vertical growth of the maxilla and (2) intrude the upper molars. •The outer bows are short so as to direct the elastic force over the center of resistance of the molars, thus avoiding any tipping of these teeth. •Eruption of lower molars is controlled with interocclusal bite blocks, which are essentially incorporated into a functional appliance that also postures the mandible forward.
  80. 80. High pull Headgear.
  81. 81. • In a long-face Class II patient with a high mandibular plane angle where intrusion of maxillary molars would decrease facial height. • Headgear line of action of force passing through the center of resistance. Outer bow must be placed somewhere along the LFO. • Effects: No moment - no change in the cant of occlusal plane. Only intrusive, distal, component of force.
  82. 82. • Indicated for class II openbite cases • Long outer bow placed posterior to this line, the moment produced will be in a clockwise direction. • Effects: steepen the occlusal plane, intrusive and distal force
  83. 83. B) High angle with deep bite- Treatment objectives are to: • inhibit growth of the maxilla and reposition it somewhat distally, • correct all habits and allow free growth of the mandible, • promote slight mesial displacement of lower teeth, • intrude upper and lower incisors, • inhibit eruption of upper posterior teeth, and • restrain anterior alveolar growth and eruption of teeth.
  84. 84. • Extra oral forces: The extra oral appliance used will be a low- or medium-pull occipital headgear. The direction of pull has to be precisely evaluated, clinically or radiographically, to orient the forces along, or even slightly above, the occlusal plane. • During treatment with the fixed appliances, the headgear will be used either in conjunction with an incisor spur or hooked directly on the upper arch between the canines and lateral incisors.
  85. 85. • In intrusion of anterior segment with base arch. Short outer bow • Angulated at higher level • Line of action of force passes anterior to center of resistance of the unit, the moment produced will be counterclockwise direction. • Effects: Distal, intrusive, flattening of occlusal plane
  86. 86. Asymmetric headgear • Asymmetrical molar relations can be corrected by transpalatal arch or lingual arch. • Same mechanism can be used with headgear. • Molar relation with class I on one side and class II on other side without any asymmetries in molar axial inclinations and rotations is the ideal indication for asymmetrical headgear
  87. 87. • Distal forces are 3 times greater on the long outer bow side than the short outer bow side. • Short outer bow side – more amount of lateral forces can result in cross bite.
  88. 88. High pull headgear to a functional appliance with bite blocks • In Class II cases associated with severe denture-base discrepancy in the growth period, it is logical to restrict the forward growth of the maxilla or maxillary dentition and, simultaneously, to stimulate all possible forward growth of the mandible. • Most effective approach to growth modification involving vertical maxillary excess and a class II relationship. • Here the force is directed entirely on to the maxilla,controls eruption of posteriors.
  89. 89. • Headgear force increases the retention of the functional appliance. • High pull headgear produces a force direction near the estimated center of resistance of the maxilla. • The functional appliance enhances the mandibular growth simultaneously controlling the eruption of anterior and posterior teeth.
  90. 90. Mandibular growth Advancer. MGA • It is a modified activator. • Functional appliance (MGA, mandibular growth advancer) with headgear have obtained jaw and occlusal relationships, that are well-balanced, both anatomically and functionally, producing a harmonious profile. • The MGA is a modified activator for gradually accommodating the muscle function by progressively advancing the mandible
  91. 91. Head gear with Functional appliance. MGA
  92. 92. Method of maxillary growth restriction: • Bands are placed on both upper first molars and maxillary growth is restricted with an extraoral appliance. • The traction force is 500 gm . • A cervical-type traction is used, but a high-pull or a straight-pull vector is used in cases where excessive molar extrusion is contraindicated.
  93. 93. Method of mandibular forward induction: • The MGA is a functional appliance for mandibular protraction. • It is composed of two separate splints fused together by self cure acrylic. • With this appliance, the mandible is advanced progressively with a mandibular splint. • The objective is to remodel the condyle and the glenoid fossa in the temporomandibular joint with concomitant adaptation of orofacial muscles.
  94. 94. Activator Headgear therapy. • An activator alone creates a force system passing behind the centers of resistance of both the maxilla and alveolar process resulting in clockwise rotation of both the palatal and occlusal planes. • Pfeiffer and Grobety described combination of activator — cervical headgear therapy: • to extrude maxillary molars, • to apply orthopedic traction to the maxilla, • to induce orthopedic mandibular changes, • restrain maxillary growth, and • cause selective eruption of teeth.
  95. 95. Activator with Headgear.
  96. 96. • Hypothetically, a simultaneous application of both appliances may result in desirable treatment effects greater than those induced by each appliance separately. • Indicated in class II div 1 cases where the dental arches are coordinated but class II correction encounters. Difficulties. • Cervical headgear with long outer bow; outer bow 5 degrees below the inner bow to produce distal force through the centre of resistance of the molar teeth and a lesser extrusive force component.
  97. 97. Comparative evaluation of a New Removable Jasper Jumper Functional applaince vs an Activator- Headgear combination. (zafer Sari, Yasar Goyenc; AO 2003). • Results suggest that ANB angle was decreased significantly with both treatment modalities. • Increase in total facial height was greater with activator-HG than with JJ-HG. • Vertical growth inhibition of lower incisors was greater with the JJ-HG. • The activator- HG was more effective on the mandible, whereas the JJ appliance was mainly active on the maxilla. • Thus ideal cases for JJ- splinted appliance should be high angle cases, particularly with maxillary excess and some mandibular deficiency.
  98. 98. Maxillary Intrusion Splint • M.I.S. is a full coverage, acrylic palatal plate with both anterior and posterior capping carried round and onto labial surfaces of the incisor teeth and extra-oral traction tubes incorporated in the base plate mesially to the cusp tip of the first premolar. • M.I.S reduces the visibility and vulnerability of the maxillary incisors by the intrusion of maxillary teeth, restraining maxillary growth, and encouraging an element of subsequent forward mandibular rotation. • Indicated in “gummy smile” patients.
  99. 99. Maxillary Intrusion Splint (M.I.S.). A)Cribs and occlusal capping combine to produce a well retained appliance. B)“Fly tubes”are incorporated independently in the base plate and are aligned mesially along the cusp tip of 4 and 5.
  100. 100. (C) Acrylic capping for the incisors and canines should cover the incisal third of the crown. (D) Occlusal coverage in the .buccal segments does not extend onto the buccal surface of the premolars and molars.
  101. 101. • vertical pull to the Kloehn bow at about 60 degrees to the occlusal plane. • The outer arm was shortened so that traction could be applied through the centre of resistance of the maxillary dentition.– dental and skeletal effects can be achieved with good vertical control. • A force of 500 g and upwards was applied bilaterally depending upon the patient tolerance. • worn for up to 14 hours per day .
  102. 102. Head gear with Herbst appliance. • The appliance consisted of cast Vitallium splints bonded to the upper and lower arches with Herbst telescopic arms inducing constant anterior mandibular jumping. • A combination of high-pull and low-pull forces was used at night to increase the force against the maxilla.A plate was constructed in the upper jaw as anchorage for a headgear to be worn 12 to 14 hours per day. • A 1000 gm force was applied against the headgear tubes intially. As the distal force from the Herbst appliance alone against the upper teeth appeared sufficient, the heavy headgear forces were reduced to 300 to 400 gm. • Headgear-Herbst treatment followed by activator retention.
  103. 103. Appliance construction: A, Splints bonded to the teeth. At far right, note Herbst telescopic arms for correction of the intermaxillary relationship with pieces of tubes for progressive jumping. B (left to right), Appliance in situ; mandible jumped to a Class I molar relationship; progressive jumping after 2 months. C (left to right), Headgear in situ; further jumping after 4 months to final stage of treatment; activator for stabilization.
  104. 104. Effects of headgear and mandibular step-by-step advancement versus conventional Herbst appliance and maximal jumping of the mandible. (Xi Du, Urban Hagg and A. Bakr M. Rabie; EJO 2002) • The herbst appliance, with high-pull headgear and stepby-step mandibular advancement, seemed to have a greater influence on maxillary jaw base position, jaw relationship and improved control over the rotation of the mandibular plane than herbst appliance without headgear and maximal jumping of the mandible. • The step-by-step advancement did not reduce the mandibular anchorage loss.
  105. 105. The effects of headgear treatment on dental arches and craniofacial morphology:a report of a 2 year randomized study. (Tuomo kantomaa, pertii pirttiniemi and aila pykalainen; EJO 2004). • The use of headgear in early mixed dentition is effective in the treatment of moderate crowding . • Space was gained in both dental arches by widening the arches and labial inclination of the incisors. With the distal force on the upper first molars, a restraint of maxillary growth distally was observed.
  106. 106. Vertical tube headgear 1989 May JCO-Jan Reurink • Buccal expansion – bend the inner bow outwards • Inner bow has to be adjusted for severe mesiopalatal rotation of the first molar • palatal bar is required • The moment of force resulting from the intrusive forces of high or vertical pull traction – can flare the molars • Horizontal extension of inner bow- can have chance of eye injuries
  107. 107. Vertical Tube Headgear Construction: • The prototype appliance used an .045" vertical tube soldered to a Dentaurum triple tube . A convertible combination bracket can also be used. • The facebow is modified simply by cutting off the horizontal extensions of the inner bow. • The vertical tube allows insertion of the facebow either from the gingival for cervical traction or from the occlusal for high pull traction
  108. 108. Vertical molar tube
  109. 109. Upward Downward
  110. 110. Safety measures and systems (JCO 2002 oct) • Check the fit of the locking facebow in a mirror, and confirm the lock by lightly pulling forward on the facebow. Then attach the safety head or neck strap at the prescribed tension (mark the appropriate holes) while holding on to the facebow. • Never wear the headgear while playing. • If someone else grabs the headgear, take hold of it until the other person lets go. Then take the headgear and facebow apart to make sure nothing has been dislodged or broken
  111. 111. • If the headgear or facebow ever comes off at night, or if there are any other problems, stop wearing it and schedule an appointment as soon as possible. • Always remove the head or neck strap before removing the facebow. • An eye injury, however minor, see an ophthalmologist immediately. Penetrating injuries may appear relatively asymptomatic, but immediate antibiotic therapy is required to reduce the likelihood of infection
  112. 112. Safety Catch Mechanism (JCO 1993 Mar) "Tom Catch“ • Hold a Kloehn facebow in the molar tubes The catch is bent from a length of .032" austenitic stainless steel wire, soldered to the end of a facebow, and attached to a buccal tube assembly. • The facebow is inserted by placing the end of the safety catch in the channel between the molar band and the buccal tube assembly. The inner bow is then compressed gingivally against the spring until the end of the bow lines up with the molar tube . While still compressed, the bow is guided posteriorly into the tube until the safety catch locks behind the tube assembly
  113. 113. Kloehm face bow with safety catch mechanism.
  114. 114. Nitom locking Face bow
  115. 115. Plastic Neck-strap
  116. 116. Face bow soldered to functional appliance.
  117. 117. Conclusion. There are a number of ways to attempt the correction of class II malocclusions. The method chosen depends on a series of factors that must be carefully evaluated before each therapy. The right indication is the formula for success. Only a careful and complete diagnosis and a continued diagnostic monitoring during treatment enables the choice of the right appliance for the individual case to assure optimal treatment.
  118. 118. Thank you Leader in continuing dental education