REVIEW ARTICLE

True molar intrusion attained during orthodontic treatment: A systematic review

Julia Ng,a Paul W. Major,b and Carlos Flores-Mirc London, Ontario, and Edmonton, Alberta, Canada Introduction: The aim of this systematic review was to quantify the amount of true molar intrusion attainable during orthodontic treatment. Methods: A literature search was conducted to identify clinical trials that assessed true molar intrusion through superimposition of lateral cephalogram tracings. Craniofacial growth had to be factored out when appropriate. Electronic databases (Pubmed, Medline, Medline In-Process & Other Non-Indexed Citations, all EBM reviews, Embase, Web of Science, and Lilacs) were searched with the help of a senior health-sciences librarian. Abstracts that appeared to fulll the initial selection criteria were selected, and the full-text original articles were then retrieved and analyzed. Only articles that fullled the nal selection criteria were nally considered. Their references were also hand-searched for possible missing articles from the database searches. Results: Thirty abstracts met the initial inclusion criteria, and these articles were retrieved. From these, 29 were later rejected because they did not either quantify true molar intrusion or factor out normal craniofacial growth when required. Only 1 article remained, and it showed a mean maxillary molar intrusion of 0.96 mm (SD, 0.54) in 12 subjects. Conclusions: True molar intrusion appears to be achievable in the maxillary arch, although the amount of evidence is minimal. The clinical signicance of the magnitude of the true intrusion reported is questionable as the sole treatment option to correct open-bite malocclusions. Better quantication method of the true intrusion attained has to be utilized. (Am J Orthod Dentofacial Orthop 2006;130:709-14)

pen-bite malocclusions with skeletal components are difcult to treat because of their high relapse tendencies.1-4 Patients with skeletal open bites often exhibit vertical skeletal-growth discrepancies, abnormal muscular and soft-tissue development, or habits that cause unfavorable tongue and orofacial muscle activity.1,2 Treatment options for open-bite malocclusions include elimination of the etiology, extrusion of the anterior teeth, surgical impaction of the maxilla, inhibition of molar eruption in growing patients, intrusion of the molars, and a combination of these.3-7 Although extrusion of the anterior teeth is often used to close an open bite, caution must be used because a patient with an anterior open bite often has shorter roots and less facial bone support of the anterior teeth.8 Compromised esthetics and a less stable outcome than for intrusion of
a

Resident, Graduate Orthodontic Program, University of Western Ontario, London, Ontario, Canada. Professor, Director of Orthodontic Graduate Program, University of Alberta, Edmonton, Alberta, Canada. c Clinical Associate Professor and Director, Cranio-facial & Oral-health Evidence-based Practice Group, Edmonton, Alberta, Canada. Reprint requests to: Dr Carlos Flores-Mir, Faculty of Medicine and Dentistry, Room 4051A, Dentistry/Pharmacy Centre, University of Alberta, Edmonton, Alberta, Canada T6G 2N8; e-mail, carlosores@ualberta.ca. Submitted, March 2005; revised and accepted, May 2005. 0889-5406/$32.00 Copyright 2006 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2005.05.049
b

posterior teeth have been also considered drawbacks of incisor extrusion in these patients.6 Molar intrusion is difcult to achieve because molars are large multirooted teeth. A patients desire to avoid surgery, endodontic therapy, or extensive prosthetic restoration, however, makes it an available option to correct an anterior open bite and overerupted molars.9 It has been established in incisors that tipping gives the clinical impression of intrusion because it affects vertical incisal edge position.10,11 Neither the incisal edges nor the root apices are good reference points because they are not independent of tooth inclination changes.12 Much like incisors, neither cusp tips nor root apices are ideal reference points to evaluate molar intrusion. The molar centroid, like that of the incisor, is a point on the longitudinal axis of the tooth that is independent of any changes in inclination; this makes it the ideal reference point.13 For incisors, the palatal plane for the maxillary molar and the mandibular plane for the mandibular molar are used as the reference structures relative to the centroid to evaluate whether true intrusion has been achieved.13-15 A systematic review is a methodologically sound process to search and analyze all available published evidence about a specic question. Well-dened search criteria, adequate selection of articles clearly related to the question, and their comprehensive analysis distinguishes a systematic review from a narrative review.
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Table I.

Database search strategy and sensitivity of the electronic databases used

% of total selected Results Selected abstracts (30)* 115 116 0 35 0 5 52 24 27 0 10 0 4 0 80.0 90.0 0 33.3 0 13.3 0

Database PubMed

Key words

(1) orthodontic*; (2) intru*; (3) molar*; (4) 1 and 2 and 3; (5) limit 4 to humans Medline (1) orthodontic$.mp or exp ORTHODONTICS; (2) intru$.mp; (3) molar$.mp or exp MOLAR; (4) 1 and 2 and 3; (5) limit 4 to humans Medline In-Process & Other (1) orthodontic$.mp or exp ORTHODONTICS; (2) intru$.mp; (3) molar$.mp Non-Indexed Citations or exp MOLAR; (4) 1 and 2 and 3; (5) limit 4 to humans Web of Science (TSorthodontic* AND TSintru*) and TS(molar*); DocTypeAll doc types; LanguageAll languages; Database(s)SCI-EXPANDED Embase (1) orthodontic$.mp or exp ORTHODONTICS; (2) intru$.mp; (3) molar$.mp or exp MOLAR; (4) 1 and 2 and 3; (5) limit 4 to humans All EBM reviews (1) orthodontic$.mp or exp ORTHODONTICS; (2) intru$.mp; (3) molar$.mp or exp MOLAR; (4) 1 and 2 and 3; (5) limit 4 to humans Lilacs (1) molar AND intrusion *Percentages do not add up to 100% because same references were found in several databases.

The present trend for evidence-based facts gives systematic reviews a signicant importance in current dental research.16 In a systematic review, it is important to cover all available evidence; therefore, efforts must be made to cover all possible databases even those not in English.17,18 Although there are claims that molar intrusion is attainable during orthodontic treatment, no comprehensive review was found in the literature. The purposes of this systematic review were to quantify the amount of true molar intrusion attainable in orthodontic patients without surgical procedures and to consider whether it is clinically signicant.
MATERIAL AND METHODS

A computerized search was conducted in the following electronic databases: Medline (from 1996 to week 2 of April 2005), PubMed (from 1966 to week 2 of April 2005), Medline In-Process & Other NonIndexed Citations (April 22, 2005), all EBM reviews (to rst quarter of 2005), Embase (from 1988 to week 17 of 2005), Web of Science (from 1945 to 2004), and Lilacs (April 25, 2005). The main terms used in the database search were orthodontics, intrusion, and molar. The selection and specic use of each term in every database search were made with the help of a senior librarian specializing in health-sciences database searches (Table I). Clinical trials and intrusion of permanent molars were considered the initial inclusion criteria to select potentially appropriate articles from the abstracts in the database searches. Surgically assisted molar intrusion was considered an exclusion criterion at this stage. Eligibility of the selected studies was determined by

reading the abstracts of the articles identied in the initial search (Table I). No attempts were made at this stage to identify studies that did not use adequate control groups to factor out growth changes. It was considered improbable that the abstracts would report enough information about control groups, and so relying too heavily on them, might exclude some useful articles. All article abstracts that appeared to meet the initial inclusion criteria were selected, and the actual articles were collected. The selection process was independently conducted by 2 researchers, and their results were compared to settle discrepancies through discussion, except for the Lilacs database, which was evaluated by only 1 researcher (C.F-M.) because of the language limitation. If the article abstract did not provide enough information to make a decision, the actual article was obtained. The actual articles from the selected abstracts were thereafter independently evaluated by the 3 researchers. A consensus was reached regarding which articles fullled the nal selection criteria and were nally included in the systematic review. Articles that did not report true molar intrusion and did not factor out growth when required (growing samples) were rejected. True molar intrusion was considered met when the selected studies used the center of resistance of the molar as the reference point to quantify the vertical movement of the molar in the dentoalveolar bone. Use of occlusal or apical points for molar intrusion evaluation can articially increase or decrease the amount of relative intrusion if tipping is part of the total molar movement; therefore, those articles were rejected.

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Vertical growth of the dentoalveolar bone was important to factor out to make an accurate assessment of the amount of true intrusion achieved. Failure to consider dentoalveolar growth would result in underestimation of the amount of intrusion attained. Although measurement error is needed for a correct interpretation of the clinical signicance of the ndings, it was not considered a reason to reject an article but was considered in the interpretation of the data. These 3 considerations were used in a previous systematic review to evaluate true incisor intrusion.19 The reference lists of the retrieved articles were also hand-searched for additional relevant articles that might have been missed in the database searches. Also, we made a hand search using the online resources of the 3 main orthodontic journals (American Journal of Orthodontics and Dentofacial Orthopedics, Angle Orthodontist, and European Journal of Orthodontics) and any additional potential references. When extra information that was not specically stated in the article was required for discussion or statistical analysis, we contacted the authors to obtain it.
RESULTS

Table II. Authors

Studies that were considered but later rejected

Methodologic limitations 1 1 1 1 1, 2 1, 3 1, 3 1 1, 2 1 2, 3 2 1, 2 1, 2 1, 3 1, 2, 3 1, 2, 3 1, 2, 3 2 1 1, 2, 3 1, 2 1, 2, 3 1, 3 1, 3 1, 3 1 1, 3 1, 2, 3

Different numbers of hits were found depending on the electronic database selected. Medline identied most of the abstracts with 112, followed by PubMed with 87, Lilacs with 50, and Web of Science with 33. The remaining databases had only a few hits. The use of the Lilacs database permitted the inclusion of article abstracts in Spanish that did not appear in English databases, but none fullled the initial selection criteria. From the total abstracts identied in the electronic databases, only a relatively small percentage fullled the initial inclusion criteria (Table I). When we compared the results between databases, Medline obtained all abstracts except 1. Medline identied 27 abstracts that were not found in PubMed, 1 of which was not found in any other database search. Of these 27 abstracts, only 4 were selected. PubMed identied 2 abstracts that were not in the Medline search, of which 1 was selected. In Medline, 85.7% of the selected abstracts were included in PubMed. In Web of Science, 9 abstracts identied were not included in the PubMed search; none was selected. All selected abstracts from Web of Science were found in PubMed. Medline In-Process, EBM, and Embase did not include abstracts not found in PubMed. Thirty article abstracts fullled the initial selection criteria. Of these, 29 were later rejected because of methodological issues. The studies were rejected because true intrusion was not evaluated,1-6,20-37 or the authors did not consider the impact of ver-

Pearson5 Pancherz44 Baumrind et al20 Barbre and Sinclair1 Dyer et al21 Everdi et al2 Orton et al22 Pancherz and Anehus-Pancherz23 Brown et al24 Everdi and Ozkan25 Ghosh and Nanda38 Wilson41 Uem and Yuksel28 Stucki and Ingervall27 Covell et al29 Pearson and Pearson30 Alcan et al31 Bussick and McNamara32 Deberardinis et al40 Sankey et al33 Heinig and Gz34 Du et al35 Stromeyer et al36 s I can et al45 Sherwood et al6 Sugawara et al3 Trisi et al37 Everdi et al4 Gurton et al7

1, True intrusion not evaluated; 2, effect of growth not considered; 3, no error of measurement stated.

tical dentoalveolar growth in children or adolescents.7,21,24,27,28,30-32,34,35,38 Studies by Dyer et al21 and Sherwood et al6 were not selected based on our inability to determine whether true molar intrusion was achieved; neither author responded to our request for additional information (Table II). Only the senior author from the remaining article39 replied and conrmed that true molar intrusion was used. Also, on the suggestion of that author, another article and a thesis were considered, but they were later rejected because they did not consider a control group to factor out normal growth.40,41 The article by Firouz et al39 was the only one that was nally selected. Those authors examined the effects of high-pull headgear on Class II Division 1 patients. The study compared a nonrandom, nonconsecutive sample of 12 adolescents (age range, 9.5 to 12.5 years) who wore the headgear for 6 months for an average of 12 hours a day. Twelve other patients served as controls. The appliance consisted of an Interlanditype high-pull headgear with head straps. A force of 500 g was applied at the level of the buccal trifurcation

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of the maxillary rst molars (center of resistance). A 0.032 0.032-in stainless steel transpalatal arch was included to maintain symmetry and arch widths, as well as to prevent molar rotation and buccal crown tipping. This retrospective study evaluated its subjects before and after treatment but did not report measurement error. The mean maxillary molar intrusion for the 12 subjects was 0.96 mm (SD, 0.54).
DISCUSSION

Although several studies claimed that molar intrusion is possible, they lacked adequate evaluations of molar intrusion. Only 1 study fullled the nal selection criteria for this systematic review.39 This shows the current lack of scientically sound studies to evaluate true molar intrusion. Although about 30 published studies evaluated molar intrusion as the principal or secondary objective, only 1 quantied it correctly.39 True molar intrusion can be evaluated only when the center of resistance of the molar is used as the reference point to quantify the vertical movement of the molar into its alveolar bone. Using the cusps or apices would not allow distinguishing true intrusion from tipping of the cusp edges or root apices; this could create a false perception of intrusion.12 An adequate plane of reference is also important because changes in these planes during treatment can clinically alter our perception of the intrusion attained. The palatal plane for the maxillary molar and the mandibular plane for the mandibular molar are most commonly used for molar intrusion evaluation because they represent the basal osseous bone for their respective teeth.42 Another point to consider when determining molar intrusion is the impact of normal dentoalveolar growth. Failure to consider dentoalveolar growth would result in underestimation of the amount of intrusion attained in growing adolescents.15 Studies that include growing patients must include nontreated control samples. From the study that met all selection criteria, it is evident that true molar intrusion with high-pull headgear is achievable.39 Subjects were included who had 3.0 to 7.0 mm Class II molar occlusions, at least 2.0-mm interlabial gaps, and increased lower facial heights. All received the same interlandi-type headgear with a force of 500 g on each side for 6 months of daily 12-hour wear. Statistically signicant (P .01) tooth movements were achieved, including a mean of 0.54 mm (0.96 mm when growth was factored in) of intrusion of the maxillary rst molars. The signicance of the reported mean intrusion value, however, might be questionable from a clinical standpoint. The error of

measurement alone might be about that amount. A relatively large variance (about 50%) in the amount of intrusion was also found, and the sample was small. Because only 1 study fullled all selection criteria, it is difcult to assess whether comparable values of true molar intrusion can be achieved by other appliances or in other types of patients. It is also difcult to determine which type of appliance would be best suited for such tooth movement. Likewise, no comparison of molar intrusion could be made between adults and children from this study alone, and the actual maximum intrusion values attainable could not be determined. Finally, most rejected studies2-4,6,7,22,29,30-34,36-38 and the selected article39 did not state measurement errors. This made the interpretation of the clinical signicance of the ndings and subsequent conclusions from their studies questionable. We must carefully consider that the amount of intrusion attained in clinical situations could be inuenced by characteristics of the dental arch, individual patient considerations, and chosen mechanics. The article by Firouz et al39 might not represent the actual values of molar intrusion that could normally be attained in clinical situations. The available evidence is not from the highest evidence-based hierarchy43; therefore, randomized clinical studies should be made to provide irrefutable evidence about obtaining true molar intrusion that is clinically signicant with current orthodontic appliances. Even though sound methodological scientic evidence about the magnitude of molar intrusion attainable is available only for high-pull headgear, several other mechanical options are available for the clinician. The use of a transpalatal arch with an acrylic bottom did not show signicant molar intrusion but helped to limit the vertical facial height increase during treatment.40 Use of magnetic appliances1 and micro screws/plates3,4,6 seemed to be a promising area to attain true molar intrusion, although this has to be conrmed with sound scientic evidence. Future studies that evaluate these mechanical options and compare them would be useful.
CONCLUSIONS

Limited evidence is available about the quantity of attainable molar intrusion. True molar intrusion appears to be achievable in the maxillary arch, but the amount of evidence is minimal. The clinical signicance of the magnitude of the true intrusion reported for high-pull headgear is questionable as the sole treatment option to correct open bites in clinical situations.

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Randomized clinical trials should be conducted to evaluate true molar intrusion and consider normal craniofacial growth.

REFERENCES 1. Barbre RE, Sinclair PM. A cephalometric evaluation of anterior openbite correction with the magnetic active vertical corrector. Angle Orthod 1991;61:93-102. 2. Erverdi N, Kucukkeles N, Arun T, Biren S. Cephalometric evaluation of crib therapy for cases of mixed dentition (open bite). J Nihon Univ Sch Dent 1992;34:131-6. 3. Sugawara J, Baik UB, Umemori M, Takahashi I, Nagasaka H, Kawamura H, et al. Treatment and posttreatment dentoalveolar changes following intrusion of mandibular molars with application of a skeletal anchorage system (SAS) for open bite correction. Int J Adult Orthod Orthognath Surg 2002;17:243-53. 4. Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open bite treatment: a cephalometric evaluation. Angle Orthod 2004;74:381-90. 5. Pearson LE. Vertical control through use of mandibular posterior intrusive forces. Angle Orthod 1973;43:194-200. 6. Sherwood KH, Burch JG, Thompson WJ. Closing anterior open bites by intruding molars with titanium miniplate anchorage. Am J Orthod Dentofacial Orthop 2002;122:593-600. 7. Gurton AU, Akin E, Karacay S. Initial intrusion of the molars in the treatment of anterior open bite malocclusions in growing patients. Angle Orthod 2004;74:454-64. 8. Harris EF, Butler ML. Patterns of incisor root resorption before and after orthodontic correction in cases with anterior open bites. Am J Orthod Dentofacial Orthop 1992;101:112-9. 9. Yao CC, Wu CB, Wu HY, Kok SH, Chang HF, Chen YJ. Intrusion of the overerupted upper left rst and second molars by mini-implants with partial-xed orthodontic appliances: a case report. Angle Orthod 2004;74:550-7. 10. Engel G, Cornforth G, Damerell JM, Gordon J, Levy P, McAlpine J, et al. Treatment of deep-bite cases. Am J Orthod 1980;77: 1-13. 11. Otto RL, Anholm JM, Engel GA. A comparative analysis of intrusion of incisor teeth achieved in adults and children according to facial type. Am J Orthod 1980;77:437-46. 12. Burstone CR. Deep overbite correction by intrusion. Am J Orthod 1977;72:1-22. 13. Kinzel J, Aberschek P, Mischak I, Droschl H. Study of the extent of torque, protrusion and intrusion of the incisors in the context of Class II, Division 2 treatment in adults. J Orofac Orthop 2002;63:283-99. 14. Weiland FJ, Bantleon HP, Droschl H. Evaluation of continuous arch and segmented arch leveling techniques in adult patientsa clinical study. Am J Orthod Dentofacial Orthop 1996;110:647-52. 15. Hans MG, Kishiyama C, Parker SH, Wolf GR, Noachtar R. Cephalometric evaluation of two treatment strategies for deep overbite correction. Angle Orthod 1994;64:265-74. 16. Bader J, Ismail A, ADA Council on Scientic Affairs, Division of Science, Journal of the American Dental Association. Survey of systematic reviews in dentistry. J Am Dent Assoc 2004;135: 464-73. 17. Juni P, Holenstein F, Sterne J, Bartlett C, Egger M. Direction and impact of language bias in meta-analyses of controlled trials: empirical study. Int J Epidemiol 2002;31:115-23.

18. Sutton AJ, Duval SJ, Tweedie RL, Abrams KR, Jones DR. Empirical assessment of effect of publication bias on metaanalyses. BMJ 2000;320:1574-7. 19. Ng J, Major PW, Heo G, Flores-Mir C. True incisor intrusion attained during orthodontic treatment: A systematic review. Am J Orthod Dentofacial Orthop 2005;129:212-9. 20. Baumrind S, Korn EL, Isaacson RJ, West EE, Molthen R. Quantitative analysis of the orthodontic and orthopedic effects of maxillary traction. Am J Orthod 1983;84:384-98. 21. Dyer GS, Harris EF, Vaden JL. Age effects on orthodontic treatment: adolescents contrasted with adults. Am J Orthod Dentofacial Orthop 1991;100:523-30. 22. Orton HS, Slattery DA, Orton S. The treatment of severe gummy Class II Division 1 malocclusion using the maxillary intrusion splint. Eur J Orthod 1992;14:216-23. 23. Pancherz H, Anehus-Pancherz M. The headgear effect of the Herbst appliance: a cephalometric long-term study. Am J Orthod Dentofacial Orthop 1993;103:510-20. 24. Brown DT, Gaudet EL Jr, Phillips C. Changes in vertical tooth position and face height related to long term anterior repositioning splint therapy. Cranio 1994;12:19-22. 25. Erverdi N, Ozkan G. A cephalometric investigation of the effects of the elastic bite-block in the treatment of Class II Division 1 malocclusions. Eur J Orthod 1995;17:375-84. 26. Kucher G, Weiland FJ. Goal-oriented positioning of upper second molars using the palatal intrusion technique. Am J Orthod Dentofacial Orthop 1996;110:466-8. 27. Stucki N, Ingervall B. The use of the Jasper jumper for the correction of Class II malocclusion in the young permanent dentition. Eur J Orthod 1998;20:271-81. 28. Uem TT, Yuksel S. Effects of different vectors of forces applied by combined headgear. Am J Orthod Dentofacial Orthop 1998; 113:316-23. 29. Covell DA Jr, Trammell DW, Boero RP, West R. A cephalometric study of Class II Division 1 malocclusions treated with the Jasper jumper appliance. Angle Orthod 1999;69:311-20. 30. Pearson LE, Pearson BL. Rapid maxillary expansion with incisor intrusion: a study of vertical control. Am J Orthod Dentofacial Orthop 1999;115:576-82. 31. Alcan T, Keles A, Erverdi N. The effects of a modied protraction headgear on the maxilla. Am J Orthod Dentofacial Orthop 2000;117:27-38. 32. Bussick TJ, McNamara JA Jr. Dentoalveolar and skeletal changes associated with the pendulum appliance. Am J Orthod Dentofacial Orthop 2000;117:333-43. 33. Sankey WL, Buschang PH, English J, Owen AH 3rd. Early treatment of vertical skeletal dysplasia: the hyperdivergent phenotype. Am J Orthod Dentofacial Orthop 2000;118:317-27. 34. Heinig N, Goz G. Clinical application and effects of the forsus spring. A study of a new Herbst hybrid. J Orofac Orthop 2001;62:436-50. 35. Du X, Hgg U, Rabie AB. Effects of headgear Herbst and mandibular step-by-step advancement versus conventional Herbst appliance and maximal jumping of the mandible. Eur J Orthod 2002;24:167-74. 36. Stromeyer EL, Caruso JM, DeVincenzo JP. A cephalometric study of the Class II correction effects of the eureka spring. Angle Orthod 2002;72:203-10. 37. Trisi P, Lazzara R, Rao W, Rebaudi A. Bone-implant contact and bone quality: evaluation of expected and actual bone contact on machined and osseotite implant surfaces. Int J Periodont Rest Dent 2002;22:535-45.

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American Journal of Orthodontics and Dentofacial Orthopedics December 2006

38. Ghosh J, Nanda RS. Evaluation of an intraoral maxillary molar distalization technique. Am J Orthod Dentofacial Orthop 1996; 110:639-46. 39. Firouz M, Zernik J, Nanda R. Dental and orthopedic effects of high-pull headgear in treatment of Class II, Division 1 malocclusion. Am J Orthod Dentofacial Orthop 1992;102: 197-205. 40. Deberardinis M, Stretesky T, Sinha P, Nanda RS. Evaluation of the vertical holding appliance in treatment of high-angle patients. Am J Orthod Dentofacial Orthop 2000;117:700-5. 41. Wilson MD. Vertical control of maxillary molar position with a palatal appliance (dissertation). Oklahoma City: University of Oklahoma; 1996.

42. Bishara SE, Athanasiou AE. Cephalometric methods for assessment of dentofacial changes. In: Athanasiou AE, editor. Orthodontic cephalometry. 1st ed. St Louis: Mosby-Wolfe; 1995. p.105-24. 43. Center for Evidence-Based Medicine (CEBM). Available at: http:// www.cebm.net/levels_of_evidence.asp. ;2005(February/25). Accessed September 25, 2006. 44. Pancherz H. Vertical dentofacial changes during Herbst appliance treatment. A cephalometric investigation. Swed Dent J 1982;15(Suppl):189-96. 45. Iscan HN, Dincer M, Gultan A, Meral O, Taner-Sarisoy L. Effects of vertical chincap therapy on the mandibular morphology in open-bite patients. Am J Orthod Dentofacial Orthop 2002;122:506-11.

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