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JLa~ 'wJ. Ashok Karad

CLINICAL Excellence In Finishing: • Current Concepts, Goals And Mechanics

Dr. Ashok Karad, BDS, MDS, M.OrthRCS [EdinJ Director, Smile Care Bandra (W), Mumbai , India .

Abstract It has been widely recognized for many years that proper finishing is of critical importance in achieving an excellent occlusal result after orthodontic appliance removal. This clinical presentation deals with defining finishing goals and achieving them with the appropriate treatment mechanics for optimal esthetics, function and stability. It highlights certain occlusal - static and dynamic - periodontal as well as esthetic parameters that provide useful guidelines for finishing in both the adolescent and adult orthodontic patient.

Keywords Finishing goals, occlusal parameters, periodontal factors.

Introduction

Stabi I ity of the orthodontic treatment resu It has been a topic of great interest to the profession since the inception of our specialty. The improvements in the position of teeth achieved after great deal of effort may be lost to varying degrees, after the removal of orthodontic appliances. Sometimes changes in tooth positions are noticed even during the period when the patient is using retention appliances. It has been recognized for many years that the stability of orthodontic treatment results at least partially depends on the way cases have been finished 1

• Orthodontic finishing still remains a continual challenge for the Orthodontist. Preadjusted Edgewise Appliances in their current variations probably represent the biggest step up the orthodontic evolutionary ladder and provide great benefits to Orthodontists in all stages of treatment, especially during finishing and detailing. However, in some cI inical situations, it requires a great deal of effort and skill to achieve an excellent occlusal result after appliance removal.

This clinical article deals with defining finishing goals and achieving them with the appropriate treatment mechanics for optimal esthetics, function and stability. It highlights certain occlusal - static and dynamic -periodontal as well as esthetic parameters that provide useful guidelines for finishing in both the adolescent and adult orthodontic patient.

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It is author's beliefthat the orthodontic finishing begins with diagnosis and treatment planning. With advances in treatment mechanics, there is hardly an abrupt stage of complicated wire bending to fine tune the tooth positions; rather it is a gradual progression toward finishing. In the management of a routine orthodontic case, it is extremely important for a clinician to define finishing goals at the beginning of treatment and continue to focus on them till the finishing stage, in o rder to achieve them with appropriate treatment mechanics. The generally acce pted treatment objectives are as follows:! ,3

1. Normal static occlusal relationships - Class I occlusion with 'Six Keys", 3mm of overjet and overbite

2. Normal functional movements - a "mutually protected occlusion"

3. Condyles in a seated position - in centric relation 4. Relaxed healthy musculature 5. Normal periodontal health 6. Optimal esthetics 7. Long-term stability of postreatment tooth positions

The purpose of this presentation is not just to outline treatment goals and discuss them in detail. It is the intent of this presentation to inform the orthodontic clinician of the importance of occlusal, periodontal and esthetic parameters, to finish orthodontic cases to the highest standards.

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Static occlusal parameters

Alignment

Proper alignment of teeth has been a fundamental objective of any orthodontic treatment approach. In July of 2000, the American Board of Orthodontics4 further clarified and quantified the static occlusal goals by providing a grading system for study casts and panoramic radiographs. In the mandibular arch, the labioincisal edges of the incisors and canines are the determinants of anterior alignment. This is because when labioincisal edges are aligned properly, the teeth look the best esthetically and they are the functioning surfaces of the mandibular anterior teeth. In the maxillary anterior segment, the lingual surfaces of the maxillary incisors and canines are used as a guideline to establish proper alignment. This is based on the fact that, these surfaces are the functioning surfaces and when aligned properly, the anteriors appear to be in their best esthetic relationship.

In the mandibular posterior segment, the buccal cusps of mandibular premolars and molars represent the functioning surfaces and they are easy to visualize intraorally. Therefore, these landmarks are used to establish the proper alignment in the posterior segments, within the patient' s acceptable archform. In the maxillary posterior segments, central grooves of the maxillary premolars and molars are used to access proper alignment. Again, these are used since they represent the functioning surfaces of the maxillary posterior teeth, and are easy to observe intraorally.

Marginal Ridges

The marginal ridges can be used as a key to achieve relative vertical positioning of the posterior teeth4. During the finishing stage, it is important to make sure that the marginal ridges of adjacent posterior teeth are positioned at the same level (Fig. 1). This will position the cusps and fossae of those teeth at the same level. Once the marginal ridges of the posterior teeth are positioned at the same relative level, then the cementoenamel junctions are also at the same relative level. This will lead to the bone levels between the adjacent teeth being flat, producing a much healthier periodontal situation for the patient.

The lack of distal root tip in the maxillary second bicuspids expressed during the finishing stage leads to discrepancy in the marginal ridge matching between

J Ind Orthod Soc 2006; 39:126-138

Fig. 1: Establishing normal marginal ridge relationships.

these teeth and the first molar. This also leads to a lack of occlusal contact in the posteriors4

Transverse relationship of posteriors

During the finishing stage, it is of paramount importance to evaluate the buccolingual inclination of the posterior teeth to achieve good intercuspation and prevent interferences during mandibular movements. This should be assessed by evaluating the relationship between the buccal and the lingual cusps of the maxillary and mandibular premolars and molars - called the 'Curve of Wilson'. In normal situation, the lingual cusp should be at the same level or within a millimeter of the same level as the mandibular buccal CUSpS4. This relationship makes the occlusal tables of posterior teeth relatively flat, therefore, promoting better contact of the maxillary lingual cusps with the fossae of the mandibular posterior teeth .

The extreme amount of mandibular posterior lingual crown torque found in many preadjusted appliance prescriptions leads to "rolled-in" mandibular posterior teeth as a result of expressed torque&'? (Fig. 2).

In the maxillary buccal segment, the palatal cusps of the first and second molars are generally slightly longer and extend slightly more occlusal than the buccal CUSpS.4 With the common use of expansion treatment often using over-expanded, commercial arch blanks or a limited amount of maxillary posterior expressed buccal root torque, palatal cusps extend occlusally beyond their normal limits (Fig. 2). This promotes inappropriate interdigitation between maxillary and mandibular posterior teeth, producing cross arch balancing interferences in the lateral mandibular excursions8 . Therefore, the buccolingual relationship of posterior teeth should be improved by flattening the curve of Wilson , minimizing or eliminating the discrepancies in the posterior overjet, and avoiding the prominence of palatal cusps by reducing the lower posterior torque and increasing the upper.7

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Asho k Karad

Fig. 2: Establishing static occlusal parameters.

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Anterior Inclination

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Optimal positioning of maxillary and mandibular incisors at the conclusion of treatment is the prime objective of any orthodontic treatment plan (Fig. 4&5). A lso, the control of undesirable incisor movement inherent with the routine orthodontic treatment mechanics would reduce amount of fine-tuning of incisor position during the finishing stage. AIQabandi et al9 reported 6°_7° of lower incisor flaring when simply leveling the curve of spee with fixed appliances. Reports have described the limitations of controlling the labial proclination of lower incisors during leveling, even with rectangular wires, especially when using d ass II elastics.9,10

Qleigh Williamsll , suggested certain guidelines to 'mally position mandibular incisors and canines for

J Ind Orthod Soc 2006; 39:126-138

Fig. 3: Cephalometric tracings A - Pre-treatment B - Post-treatment C - Pre and Post-treatment superimpositions

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long-term stability. The lower incisor apices should be spread distally to the crowns, and the apices of the lower lateral incisors must be spread more than those of the central incisors (Fig. 6). Apex of the lower cuspid should be positioned distal to the crown. All four lower incisor apices must be in the same labiolingual plane. The lower cuspid root apex must be positioned slightly buccal to the crown apex.

The overall inclination of the maxillary and mandibular anterior teeth is best evaluated with a lateral cephalometric radiograph. The interincisal angle plays an important role in esthetics, function and stability and should not be based on averages. 12 Growth direction, esthetics and overbite should also be considered in determining ideal torque in the maxillary and mandibular arch. In short, it should be individualized.

If uncontrolled flaring of the lower incisors is permitted, then increased labial crown torque of the maxillary incisors would be required to maintain appropriate overbite/overjet and in the process, more bimaxillary protrusive results will be produced, which will be detrimental to facial esthetics.

Molar position

Insufficient thickness of maxillary second bicuspids causes first molar to rotate mesially upon initial wire engagement, causing an increase in Class II tendency

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Fig. 3: Limited amount of maxi llary posterior buccal root torque and the extreme amou nt of mandibular posterior buccal root torque, lead ing to improper interd igitation, increased buccal overjet, and balancing interferences. (Courtesy - Dr. Jay Bowman)

Fig. 6: Optimal lower inc isor positioning with progressive distal root spread.

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Fig. 4 : Improved bucco lingual relat ionship of posterior teeth by reducing the lower posterior torque and increas-ing the upper.

Ashok Karad

Fig. 5: Normal interinc isal relation-ship, overjet and overbite achieved by optimal inc isor torque contro l.

Fig. 7: Position of maxillary second bicuspid - a key to a properly treated maloccl usion.

Fig. 8: Proper location of contact points.

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Sondhi IJ demonstrated the production of " inappropriate or broken contacts between mandibular first and second mol ars " due to the distal offsets of the first molar attachment found in some popular prescriptions. This offset can displace second molars to the lingual and/ or rotate the first and second molars to the mesial, thereby, creating an incorrect match of the adjacent marginal ridges and contact points.

These discrepancies of treatment must be carefully evaluated and addressed during the finishing stage in o rder to promote proper proximal contacts, marginal ridges and alignment in the buccal segments.

Maxillary second bicuspid - a key to occlusion

Ri cketts '4 pointed out that the contact position of the max illary second premolar is a key to a properly treated malocclusion. The maxillary second premolar should have a normal contact relation with the mesial incline of the lower first molar which produces an interlocking into the corresponding interspaces of the lower premolars (Fig. 7). This relationship causes the tip of the mesiobuccal cusp of the upper first molar to be sli ghtly distal to the mesiobuccal grove of the lower f irst molar. According to Ricketts this is the most effi c ient, most self-cleansing and most self-preserving relationship in accordance with Nature's plan.

Contact points

The importance of proper contact points between the teeth in preventing food impaction and stability of the dental arches after orthodontic treatment has been well understood by all specialists. During the finishing stage, three dimensional control of teeth positions and their relationship with the adjacent teeth is essential to establish the location of contact points. Contact points or contact surfaces of teeth are generally located in the occlusal one third of the proximal walls, slightly buccal to the central fossa in the molar and premolar area with the exception of the maxillary first and second molars ,s

,'6 (Fig. 8). The contact point between the maxillary central incisors is located at the most incisal

J Ind Orthod Soc 2006; 39:126-138

one third having a perception of a vertical line. The position of contact poi nts in the maxi lIary anterior segment, when viewed from front, seems to progress from the incisal to cervical , from the central incisors to the canine (Fig. 8).

Contact points must be observed from two aspects in order to obtain the proper perspective for their proper location; the labial or buccal aspect, and the incisal or occlusal aspect.

Occlusal contact

After the resolution of malocclusion, teeth need to be individually settled into their final positions before appliance removal. In the posterior segment, teeth are generally held away from each other in vertical plane due to full size rectangular stainless steel finishing archwires . The vertical settling of maxillary and mandibular teeth to achieve maximum intercuspation is done by using different configurations of vertical elastics. The more precise the placement of brackets and tubes, the easier it is to settle the teeth and the less elastics need to be used in this way. The adequacy of posterior teeth interdigitation is evaluated by assessing the contact relationship between the cusps and fossae of the molars and premolars. Ricketts '4

pointed out that, without third molars, 16 to 24 occlusal stops or centric stops on each side are adequate for a good balanced occlusion .

The lingual cusps of the maxillary premolars and molars should be in contact with the marginal ridges or fossae of the mandibular premolars and molars4 . In addition, the buccal cusps of the mandibular premolars and molars should contact the fossae or marginal ridges of the maxillary molars and premolars4 Due to lack of an adequate occlusal table, the lingual cusps of the maxillary first premolars may not establish contact with the mandibular first premolar.

Dynamic occlusal relationships

In addition to achieving the occlusal relationships in Class I as suggested by Angle ' 7 and the 'six keys to occlusion ' by Andrews 1s, other workers I ike Williamson19, Aubrey20, Ricketts21, and Roth 22 have all expanded the area of knowledge in occlusion to include the neuromuscular and bony structures of the TMJ in establishing orthodontic treatment objectives. In dealing with the various elements of functional occlusion as one of the finishing goals, it is important

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Fig. 9: Estab lishing functional occlu sa l goals C - Mand ibular right lateral excursion, 0 - Protrusive mandibu lar movement, E - Mandibu lar left lateral excursion.

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Fig. 10: Post-treatment intraoral and extraora l photographs.

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to achieve stable centric relation of mandible with maximum intercuspation of the teeth at this position. In the intercuspal position and retruded contact position the mandible should be situated in the same sagittal plane, the distance between the two positions being less than 1 mm.

There should be harmonious glide path of anterior teeth. These teeth should work against one another to separate or disclude the posterior segments as soon as the mandible moves out of centric closure. The proper overbite and overjet established after orthodontic treatment should allow for a gentle glide path.

The canines should provide the main gliding inclines for lateral excursions, with no interferences on the balancing side (Fig. 9). The six mandibular anterior teeth and mandibular first bicuspids should articulate with the maxillary six anteriors during mandibular protrusive excursion. In this way, a protrusive load is spread over fourteen anterior teeth with no interferences in the posterior region (Fig. 10). The teeth shou Id not prevent the mandible from entering or leaving any possible position that the joints will allow. Therefore, the teeth should direct and maintain the centricity of the condyles in their fossae on closure.

Interincisal relationship - a critical element of functional occlusion

The optimal position of maxillary and mandibular incisors and their relationship with each other after orthodontic treatment is one of the key elements of functional occlusion. According to McHorris,23,24 in the optimal functional occlusion, the anteriors are in very close approximation but do not touch when molars are in occlusion. The lower anteriors engage the lingual incline of the opposing upper anteriors immediately with mandibular movement. The lingual discluding surface of the upper anteriors seems to reflect the anatomical angle or discluding pathway of the mandibular condyles. The ideal anterior disclosure angle is greater than or equal to 5 degrees than the condylar disclosure angle (Fig. 11).

An occlusal interference on the anterior teeth, identified duri ng unforced closure of the mandible, sometimes associated with a distalizing effect in condylar position has been termed as "anterior interference.25 The axial incli nations of maxillary and mandibular anteriors and the consequent interincisal angle should be proper in order to avoid anterior interferences after orthodontic treatment.

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Fig. 12: The ideal angle of disclusion in protrusive is thought to be 5 degrees greater than the condylar disclusive angle.

Periodontal Factors

One of the finishing goals of orthodontic treatment is to position the roots of adjacent teeth parallel to each other. Other factors being normal, if the roots are parallel to each other, then there will be sufficient bone between the roots of teeth. It is considered that more interproximal bone will provide greater resistance to periodontal bone loss if the patient develops periodontal disease in the future. During the finishing stage, if the teeth are not properly uprighted, especially when the second bicuspids or first molars are extracted /missing and the posterior teeth are drifted into that space; then the marginal ridges will not be level, proximal contacts will be faulty, with angular bony defects on the mesial aspects of the mesially tipped teeth.

Another clinical situation which demands parallelism of roots of the adjacent teeth is when the maxillary lateral incisor is missing. If the maxillary lateral incisor is missing and the treatment plan involves sufficient opening of lateral incisor space and subsequent restoration with an osseointegrated implant, then it is important to evaluate the position of the roots of adjacent teeth radiographically. The roots of the central incisor and canine should be parallel to each other with adequate space between the roots for implant placement.

Crown Width Discrepancy

Size of the teeth is one of the most important elements of anterior dental esthetics. Orthodontists are often faced with disproportionate widths of anterior teeth during treatment. This tooth size discrepancy is

commonly found in patients with peg-shaped lateral incisors. Even after getting the teeth perfectly aligned and the arch forms properly establ ished with orthodontic treatment, the abnormal shape and smaller size of lateral incisor pose esthetic problems.

The Golden proportion can be called the building blocks of nature itself. This ratio is an ideal ratio that can be mathematically defined as 1 :1.618 (Fig. 12). It has been observed that when this rule of good proportion is followed, the result is something that is naturally attractive and pleasing to the eye. Smiles can be made attractive by following these mathematical rules of nature to create harmony, symmetry, and proportion. 16

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We can use the proportion to define the length: width for each tooth, Also the width of central incisor is in golden proportion to the lateral incisor width which in turn is in proportion with the mesial width of the Canine26.

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Fig. 13: The Golden proportion-an ideal ratio can be mathematically defined as 1 :1.618.

It is therefore imperative to restore the size of the malformed lateral incisors after the completion of orthodontic treatment for good overall treatment result (Fig. 13 & 15). Duringthe finishing stage of orthodontic treatment, if excessive space exists in the anterior segment, it should be redistributed to restore the proper crown width (Fig. 14). If insufficient space exists to restore these teeth, an adequate space should be gained which will permit the restoration of proper crown width. To determine the space required to restore the crown width, during the treatment planning stage, construction of a diagnostic wax-up is an important step to visualize the final result. After removal of the fixed orthodontic appliances, provisional restorations should be given before final restorations to avoid relapse.

Replacement of missing laterals with implants

Dental agenesis occurs quite frequently, espeCially of the maxillary lateral incisors, and it presents a true

J Ind Orthod Soc 2006; 39:126-138

challenge to an esthetic solution. For a long time, many clinicians had suggested an alternative treatment approach by moving the entire lateral segment mesially to place the cuspid in the lateral incisor position, However, this approach ends up with compromised results that do not fulfill the esthetic requirements of good orthodontic treatment, since the cuspid has a very different crown and root shape to that of the lateral incisor, as well as a darker shade. When missing lateral incisor space is closed by moving the entire lateral segment mesially, lateral excursions are made using bicuspids, which have shorter, thinner roots; thus, functional requirements are also not fulfilled either.

If fixed restoration is the treatment of choice, it requires reshaping neighboring teeth, with consequent removal of varying amounts of enamel, and eventual risk of gingival recession , caries etc. The osseo-integrated implant is the most conservative and biological method, since the missing tooth can be replaced without damaging the neighboring teeth.

If the use of implants is the part of treatment plan for the missing lateral incisors, it is necessary to decide the exact placement of implants, evaluate the smile line and gingival contour. When the lateral incisors are missing, there is usually no adequate space to restore them due to drifting of the adjacent teeth (Fig. 16). In such cases, it is essential to gain adequate space with orthodontics for the placement of implant and crown restoration for good esthetic result (Fig, 17). The exact amount of space created should be according to the proposed size of lateral incisors, which should be proportionate to the width of the central incisors, After opening up of sufficient space, acrylic teeth may be selected closer to the shade of the patient's teeth, bracketed and attached to the arch wire for esthetic purposes. Before the orthodontic appliances are removed it is important to evaluate radiographically the position of the roots of adjacent teeth

The roots of the central incisors and canines on either side in case of bilaterally missing laterals should be parallel to each other with adequate space between the roots for implant placement (Fig. 18 & 19). Before removal of orthodontic appliances, it is common to see adequate space for the prosthesis and inadequate space between the roots of the adjacent teeth for an implant. This usually occurs due to tipping movement of adjacent teeth, which requires proper uprighting of the roots during the finishing stage of orthodontic

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Fig. 14: Class 1 maloccl usion with disproportionate crown w idths of anteriors due to peg-shaped laterals. Fig. 15 : Proper distribution of anteri or spaces to restore normal widths of latera l incisors. Fig. 16: Peg-shaped latera ls are restored w ith ceramic veneers in a golden proportion with adjacent teeth.

Fig. 17: M axi llary lateral incisor is missing and the adjacent teeth are drifted into the space.

Fig. 18: Sufficient space has been created orthodonti ca ll y to restore maxillary right lateral inc isor.

Fig. 19: Intraora l periapical radiograph shows adequate space between the roots of the central inc isor and canine. Note the paralle lism of roots of the adjacent teeth.

Fig. 20: Osseointegrated implant placement in the latera l inc isor reg ion.

Fig. Fig.

Fig.

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21: Normal gingival archi tecture. 22: Faulty maxillary anterior resto ration vio lating the biologic w idth and

discrepancy in gingiva l margins and gingiva l zenith . 23: After the different ial forced eruption of incisors, the crown extension

procedure has been planned on upper right central and latera l incisors to resolve the res idual gi ngival discrepancy.

24: The combined orthodontic and restorative treatment exhibiting normal gingival architecture with physiologic positioning of fi nishing margins of anterior restorat ion.

treatment. The minimum space of 6.5mm between adjacent roots is required to place a standard implant of 3mm width.

Gingival Architecture

Color, contour and the health of the gingival tissues provide the framework and backdrop for the esthetic smile. Even if the case is well finished with orthodontic treatment, abnormal ity of the gi ngiva either in the form of loss of papilla, asymmetrical pattern and excessive display. leads to a poor result. It is therefore essential to have proper gingival architecture and display to achieve a maximum esthetic result. As a general rule, a line drawn at the level of the free gingival margin of the anterior segment will show the free gingival margin of the centra l incisors and the cuspids to be at the same height and that of the lateral incisors to be slightly coronal 28 (Fig. 20).

Furthermore, the most apical point of the gingiva or the gingival zenith is located just distal of the long ax is of the central incisors and cuspids, whereas the gi ngival zenith for the lateral incisors coincides with their long axis l 6,29 (Fig. 20). In other words, the height of the gum line across the face of the tooth should be centered on the lateral incisors, and positioned in the dista l 1 /3rd of the face of the tooth for the centrals and canines. This gives the gingiva a semi-circular appeara nce for lateral incisors and an elliptical appearance for central incisors and canines.

During the process of eruption the whole periodontal paratus is carried with the erupting tooth. When there

- asymmetric eruption of the teeth it will also result in repancies in heights of the underlying crestal bone.

is, in turn, results into asymmetries in gingival 'ghts (gingival zenith) from one side of the arch to

other. This type of a clinical situation can be aged orthodontically by intrusion or extrusion of

(Fig. 21, 22 & 23).

rn orthodontic treatment is aimed at creating the poss ible occlusal relationships within the w ork of acceptable facial esthetics and stability

occlusa l result. It is extremely important for a - 'an to define finishing goals at the begining of

ent and continue to focus on them till the i ng stage, in order to achieve them with pr iate treatment mechanics. This article has

J Ind Orthod Soc 2006; 39:126-138

provided certain occlusal - static and dynamic -periodontal as well as esthetic parameters that outline useful guidelines for finishing in both the adolescent and adult orthodontic patient. Also, choosing the best possible treatment options from other specialties and combi ni ng them as a part of the optimal treatment plan based on scientific rationale should be the aim for the benefit of the patient.

Acknowledgements

I thank Dr. Ratnadeep Patil for his clinical assistance in rendering Perio-restorative treatment when indi-cated. Sincere thanks to Ms. Arlene Fernandes, Dr. Kavita Ramanathan and Dr. Ken DCunha for their pro-fessional assistance in preparing this manuscript, and Mr. Nikhil Patel for his assistance in imaging.

Communications

Dr. Ashok Karad, BDS, MDS, M.OrthRCS [Edinl Diplomate, Indian Board of Orthodontics Director, Smile Care, India Smile Care, 13, Geetanjali , 234, S.v. Road, Bandra (west), Mumbai 400050. India Tel: 022-26431670/71 Fax: 022-6416342 e-mail: smile@bom7.vsnl.net.in

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