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CASE REPORT

Treatment of an adult with several missing teethand atrophic old mandibular first molarextraction sites

Armando Yukio Saga,a Ivan Toshio Maruo,a Hiroshi Maruo,b Odilon Guariza Filho,c Elisa Souza Camargo,c

and Orlando Motohiro Tanakab

Curitiba, Paran�a, Brazil

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This report describes the orthodontic treatment of a woman, aged 34 years 2 months, with several missing teethand atrophic mandibular first molar extraction sites. We had planned to close the spaces from the missing max-illary canines with mesial movement of the premolars and molars. In the mandibular arch, protraction of the sec-ondmolars into first molar extraction sites and reduction of themandibular incisor protrusion were performed. Nominiscrews or bone plates were used. Amodified helical loopwas used, and it can be considered a simple and anefficient orthodontic method of closing the spaces without mesial or lingual tipping and rotation. Pleasing estheticand functional results were achieved. (Am J Orthod Dentofacial Orthop 2011;140:869-78)

Orthodontic treatment for patients with severalmissing teeth is challenging. Orthodontists areoften confronted with adults who have large

edentulous spaces in the molar areas or need molar ex-tractions. Adults needing comprehensive orthodontictherapy often have dental and periodontal problemsthat require multidisciplinary treatment approaches.Such problems include periodontal defects, missingteeth, and atrophic extraction sites.

Proffit et al1 described several common sequelae ofmissing mandibular first molars, such as tipping anddrifting of adjacent teeth, poor interproximal contacts,poor gingival contour, reduced interradicular bone,and supereruption of unopposed teeth. Since the bonecontour follows the cementoenamel junction, pseudo-pockets form adjacent to the tipped teeth. In adults,closing an extraction site with bone defects is a challengefor orthodontists. Typically, several years after the

the Graduate Dentistry Program, Orthodontics, Pontifical Catholic Univer-f Paran�a, Curitiba, Paran�a, Brazil.raduate student.ssor.ciate professor.uthors report no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Orlando Motohiro Tanaka, Pontifical Catholic University of�a-PUCPR, Graduate Dentistry Program, Orthodontics, R. Imaculada Con-, 1155, CEP: 80215-901, Curitiba, Paran�a, Brazil; e-mail, [email protected], December 2009; revised and accepted, June 2010.5406/$36.00ight � 2011 by the American Association of Orthodontists..1016/j.ajodo.2010.06.027

extractions, bone remodeling results in narrowing ofthe alveolar ridge; therefore, closure of the extractionspaces requires remodeling of cortical bone. Addition-ally, malocclusions in adults can be complicated by themigration of adjacent teeth into the extraction sites. Un-der these circumstances, functional and esthetic resultsmight only be achieved with the combination of surgery,orthodontic treatment, and prosthodontic rehabilita-tion. The aim of this case report was to present the inter-disciplinary treatment of an adult patient with severalmissing teeth, preexisting extraction spaces, and someperiodontal and esthetic problems that required appliedorthodontic mechanics.

ETIOLOGY AND DIAGNOSIS

The patient, a woman, aged 34 years 2 months, wasreferred for orthodontic evaluation by her general den-tist. Her chief complaints were her dissatisfaction withher smile and the spaces in the maxillary and mandibulardental arches. Her medical history showed no contrain-dication for orthodontic therapy. Extraoral examinationshowed symmetric facial structures, and lip competencecould be achieved at rest with no strain. She had a slightlyconcave profile, and the upper lip was retruded relativeto the lower lip. Her nasolabial angle was normal (Fig 1).

There were no signs or symptoms of temporoman-dibular joint dysfunction. Mandibular movements,such as maximal opening and lateral and anterior dis-placement, were within normal limits. Intraoral analysisshowed coincidence of the maxillary and mandibulardental midlines relative to the facial midline. Overjet

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Fig 1. Pretreatment facial photographs.

Fig 2. Pretreatment intraoral photographs.

870 Saga et al

was 3 mm, and overbite was 2.5 mm. A negative spacediscrepancy (�2 mm) was present in the mandibular in-cisor region. The mesiodistal width of the maxillary lat-eral incisors was narrowed, and the maxillary canineswere not visible intraorally. Surgical extraction of themaxillary left canine was reported by the patient. Themandibular first molars and maxillary left first molarhad been extracted because of extensive caries whenshe was an adolescent, and the alveolar ridges wereatrophic and narrowed.

The edentulous spaces mesial to the mandibular sec-ond molars measured 8 mm on the right side and 7 mmon the left side. The buccolingual widths of atrophic

December 2011 � Vol 140 � Issue 6 American

bone were 5 mm on the right side and 4 mm on theleft side. The mandibular second and third molars andthe maxillary left second and third molars had tippedand drifted mesially. The mandibular third molars werepresent and anatomically normal (Fig 2). She had a max-illary removable partial denture, but she was displeasedwith the esthetic appearance, and it was uncomfortable.

Although the first molars and maxillary canines weremissing, the premolars had a Class II relationship. The in-tercanine width was 24 mm, and the intermolar widthwas 47 mm. The curve of Spee was moderate (Fig 3).

The panoramic radiographs showed no caries or pa-thology. The maxillary right canine was dilacerated and

Journal of Orthodontics and Dentofacial Orthopedics

Fig 3. Pretreatment dental casts.

Fig 4. Pretreatment panoramic radiograph.

Fig 5. Pretreatment cephalometric radiograph.

Saga et al 871

impacted in an oblique position. The maxillary right firstmolar, second premolar, and lateral incisor, as well as theleft central and lateral incisors, had been treated end-odontically. The mesial region of the maxillary secondmolar had a significant periodontal bone defect (Fig 4).

The cephalometric radiograph and analysis con-firmed the maxillary protrusion and a well-positionedmandible (SNA, 85�; SNB, 80�). Although the ANB of5� suggested a skeletal Class II pattern, profile variablesshowed that the upper lip was retruded relative to thelower lip (upper lip to S line, �4 mm; lower lip to S

American Journal of Orthodontics and Dentofacial Orthoped

line, �3.5 mm). Her facial form was considered mesoce-phalic (GoGn to SN, 39.5�; FMA, 26.5�). Dentally,the maxillary incisors were well positioned (U1 to NA,5 mm; U1 to NA, 23�). The mandibular incisors were

ics December 2011 � Vol 140 � Issue 6

Table. Cephalometric measurements

Variable NormPretreatment

(T1)Posttreatment

(T2) (T2-T1)SNA (�) 82 85 85.5 0.5SNB (�) 80 80 80 0ANB (�) 2 5 5.5 0.5GoGn to SN (�) 32 39.5 38 �1.5FMA (�) 25 26 26.5 0.5FMIA (�) 67 65.5 69 3.5IMPA (�) 88 88.5 84.5 �4U1 to NA (�) 22 23 9 �14U1 to NA (mm) 4 5 0 �5L1 to NB (�) 25 29 24 �5L1 to NB (mm) 4 8 5.5 �2.5Interincisalangle (�)

131 123 141 18

Pog to NB (mm) - 0 0.5 0.5Upper lip toS line (mm)

0 �1.5 �1 0.5

Lower lip toS line (mm)

0 0.5 0 �0.5

872 Saga et al

protrusive (L1 to NB, 8 mm) and also proclined relative tothe cranial base (L1 to NB, 29�) with a closed interincisalangle (123�) (Fig 5, Table).

TREATMENT OBJECTIVES

1. Extract the impacted maxillary right canine andobtain a Class I relationship between the maxillarypremolars and the mandibular canines.

2. Improve smile esthetics by aligning and levelingboth dental arches, closing the space of the maxil-lary canines with mesial movement of the premolarsand molars, and increasing the mesiodistal width ofthe maxillary lateral incisors.

3. Prepare space for dental implants in the maxillaryleft first molar area.

4. Protract the mandibular second molars into the firstmolar extraction sites.

5. Improve the facial profile.6. Obtain normal overjet and interincisal guidance.7. Reduce the mandibular incisor protrusion.

TREATMENT ALTERNATIVES

Surgical exposure and orthodontic traction could bea possible approach for management of the impactedmaxillary right canine. However, there was not adequatespace to move the canine into correct alignment and toincrease the mesiodistal width of the lateral incisor. So,since the maxillary right first premolar was in a Class I re-lationship with the mandibular right canine, it would benecessary to distalize the maxillary posterior teeth or ex-tract a tooth (premolar or molar). The maxillary right ca-nine was dilacerated and impacted in an obliqueposition, and it would also be difficult to retract withoutroot resorption.

We could visualize closure of the maxillary left firstmolar space. But it was not the choice of treatment be-cause of the vertical and buccolingual bone defect. Thus,a dental implant was indicated.

A practical way to solve the problem of the missingmandibular teeth would be to open space to insert den-tal implants in the mandibular first molar areas. Never-theless, the patient preferred to reduce the surgicalprocedures, the number of dental restorations, andcosts. Hence, the closure of those spaces with protrac-tion of the mandibular second molars and retraction ofanterior teeth into the maxillary left first molar areawas the choice of treatment.

TREATMENT PROGRESS

At the start of the treatment, the patient was referredto a surgeon to extract the maxillary right canine. After


the appropriate healing time, all maxillary and mandib-ular teeth were bonded with 0.022-in nontorqued, non-angulated edgewise brackets, except for the mandibularsecond and third molars. The archwires progressed from0.016-in nickel-titanium, 0.016-in stainless steel,0.018-in stainless steel, to 0.020-in stainless steel arch-wires to align and level all teeth.

After alignment, a nickel-titanium compressed coilspring on a 0.020-in stainless steel archwire was usedto open the space between the maxillary central and lat-eral incisors. Then, the patient was referred to her dentistto restore the mesiodistal width of the maxillary lateralincisors. The remaining spaces between the maxillaryteeth were closed with an 0.0183 .025-in stainless steelwire with an 8 3 4-cm helical loop distal to the lateralincisors. The mandibular second molars were bondedand an 0.0183 0.025-in stainless steel wire with a mod-ified helical loop inserted to retract the anterior teethand protract the mandibular molars. Initially, the secondmolars were uprighted by using the helical loop openedpassively without any protraction force (Fig 6), and themolars were tied to the distal small loop to shift thecenter of rotation of the second molars coronally.

Therefore, the helical loop worked passively as analigning and leveling loop. After second molar upright-ing, the helical loops were activated to protract the mo-lars and retract the incisors at the rate of 1 mm at eachappointment. Effective tipbacks of 20� to 30� were ap-plied to correct the mesial molar tipping. A slight toe-in bend was necessary to prevent mesiolingual rotationof the molars. Some labial crown torque of the mandib-ular incisors and anterior vertical and Class II elastics


Fig 6. Progress applied mechanics diagram: mandibularsecond molar uprighting.

Fig 7. Progress applied mechanics diagram: mandibularsecond molar protraction and incisor retraction.

Fig 8. Progress applied mechanics diagram: mandibularthird molar bonding and finishing.

Saga et al 873

were required as auxiliary mechanics to prevent exces-sive retraction of the incisors (Fig 7). No miniscrews orbone plates were used. After all spaces were closed, themandibular third molars were bonded. Further finishingand detailing were performed with 0.019 3 0.025-instainless steel wires in both arches (Fig 8). Then the ap-pliances were removed, a maxillary Hawley retainer wasplaced, and a mandibular lingual wire retainer wasbonded from canine to canine.

TREATMENT RESULTS

At the end of the treatment, space closure was ob-tained with moderate improvement in the facial profile(Fig 9). The dental examination showed satisfactory pos-terior occlusion, good interdigitation of the teeth, and


an acceptable overjet and overbite relationship. Goodtooth alignment with a Class I relationship betweenthe maxillary first premolars and the mandibular canineswas obtained (Fig 10). Because of the shortened heightof the premolars when compared with the canines,a group functional occlusion was created. But themain result was closure of the atrophic ridges withoutgreat periodontal complications. Bodily movement ofthe molars was noted, with the roots moving muchmore than the crowns bilaterally. The intercanine widthwas maintained at 24 mm, and the intermolar width wasreduced from 47 to 44 mm (Fig 11). The panoramic ra-diograph shows uprighting of the mandibular secondmolars. The mandibular third molars were also some-what uprighted (Fig 12). As seen in the cephalometricsuperimposition, the maxillary anterior teeth were bodilyretracted with intrusion, and the maxillary and mandib-ular posterior teeth were uprighted and moved mesially.The mandibular anterior teeth were retracted with up-righting (Fig 13). Since the mandibular incisors were re-tracted by 2.5 mm (L1 to NB), the mandibular molarswere protracted by approximately 5.5 mm on the rightside and 4.5 mm on the left side. Root resorption wasminimal for both molars, even though they had trans-lated through the atrophic bone.

The anteroposterior relationship (ANB) was main-tained, and the vertical pattern (GoGn to SN line) was di-minished, probably because of mesialization of themandibular molars. The mandibular incisors were up-righted from 88.5� to 84.5�, the upper lip to S line wasimproved from �1.5 to �1 mm, the lower lip to S linewas improved from 0.5 to 0 mm (Fig 14, Table). All thesechanges contributed to improving the facial profile.Some recession of the gingival margin was observed


Fig 9. Posttreatment facial photographs.

Fig 10. Posttreatment intraoral photographs.

874 Saga et al

on the mandibular molars, but no mobility or discomfortwas evident, and periodontal maintenance was recom-mended. Treatment lasted for 3 years 9 months, the ob-jectives were accomplished, and the patient was pleasedwith the final results.

DISCUSSION

Precise control of tooth movement during closure ofextraction spaces in 3 dimensions is of paramount im-portance in meeting treatment goals.2 The large rootsurfaces of the mandibular molars make their movementuncertain and simultaneously cause unwanted tooth


movements such as lingual tipping of the incisors. So,differential moments are used for obtaining differentialanchorage, intrusive or extrusive forces, and root move-ment. Anchorage control is important in the treatmentof these patients, because excessive lingual tipping ofthe mandibular incisors must be prevented while pro-tracting the second molars.3 To obtain the desired forcesystem while edentulous spaces are being closed, the cli-nician should consider various situations such as thepresence or the absence of other permanent teeth, therelationship with opposing teeth, the amount and siteof the crowding, the amount of mesial or lingual tippingof the molars, and the need for anchorage.4


Fig 11. Posttreatment dental casts.

Fig 12. Posttreatment panoramic radiograph.

Saga et al 875

Tweed tip-back bends, Begg or tip-edge mechanics,intermaxillary elastics, and headgear can produce dif-ferent moment-to-force ratios between the anteriorand posterior teeth. This difference in the moment-to-force ratio acting on the anterior vs the posteriorteeth is produced by applying either unequal moments(a moment differential) or unequal forces.2 Kulhberg


and Burstone2 demonstrated that a centered T-loopproduces equal and opposite moments with negligiblevertical forces, and off-center positioning of a T-loopproduces differential moments. More posterior posi-tioning produced an increased beta moment, andmore anterior positioning produces an increased alphamoment. So, following this reasoning, in our case, thehelical loop was placed distally to the mandibularsecond premolars.

Space closure after extraction of the first permanentmolars has been studied in some detail and has led toconclusions about the results achieved in children andyoung adults.5 Adults showed less bone appositionwhen moving second molars into the narrowed space,poor maintenance of the closed space, and, in somecases, resorption of the second molar roots. Other au-thors concluded that complete closure could be achievedwith the roots of the second molars moving almost twiceas far as the crowns.6 They agreed that most patientsshowed crestal bone loss mesially to the second molarsafter treatment, but suggested that root resorption ofthe second molars was only minimal. This light force


Fig 13. Superimposition of cephalometric tracings: black, Pretreatment; red, posttreatment.

Fig 14. Posttreatment cephalometric radiograph.

876 Saga et al

delivered from the helical loop seemed to be suitable toclose the atrophic bone spaces. In our patient, the sideeffects observed during the closure of the missing man-dibular molar spaces were acceptable.

Although some vertical bone loss and gingival reces-sion occurred, the second molars were not mobile orpainful. If mandibular first molar implants had beenchosen, augmentation of the buccolingual bone thick-ness with autogenous or allogenic bone grafts wouldhave been necessary. It was assumed that, if the bucco-lingual width of the alveolar crest were constricted, thesecond molar should not be moved mesially, becausethis would result in loss of bone support.7 Accordingto Zachrisson,8 orthodontic tooth movement is an excel-lent way (maybe the best and most predictable method)to regenerate new alveolar bone and soft tissue. It wasspeculated that bone defects resulting in atrophy ofthe alveolar ridge could be repaired by guided bone re-generation and decalcified freeze-dried bone allograftsbefore orthodontic tooth movement. However, thetype and magnitude of the lesion as well as clinical var-iability will highly influence the success rate of regener-ative procedures.9 Other research has demonstratedsuccessful long-term follow-ups when a premolar ismoved orthodontically into an edentulous space.10,11

In our patient, the implant was placed in the positionoccupied previously by the premolar and was restoredwith an implant-supported crown. We decided to closethe remaining mandibular extraction sites to eliminatethe need for additional surgical procedures or implants,and also to decrease the treatment expenses.


Ideal dimensions for successful mandibular first mo-lar space closure are reported to be 6 mm or less of me-siodistal space and 7 mm of buccolingual width.6

Although in this patient the mesiodistal dimension ofthe extraction spaces (8 mm on the right side, 7 mmon the left side) were greater and the buccolingualwidths were narrower, complete closure of the extractionsites without molar tipping was successfully achievedwith orthodontic tooth movement. Because of the


Saga et al 877

posterior divergence of the mandible, the mesial move-ment of the molars reduced the intermolar width from47 to 44 mm, placing the molars in a narrower area ofthe mandible.

The patient had good plaque control throughout theorthodontic treatment. So, vertical bone loss around themandibular second molars probably occurred because ofthe mesial molar movement. If first molar implants hadbeen chosen, some peri-implant bone loss would havebeen expected.12 Although the maxillary third molarshad been bonded, the final occlusion was obtainedwith an active Hawley retainer that improved the lingualcrown torque.

Some root proximity between adjacent roots was ob-served on the posttreatment panoramic radiograph. Theperiapical radiographs did not show such a hopeless sit-uation. The proximity between the maxillary left centraland lateral incisors occurred because of the alteredcrown morphology of the lateral incisor. After the align-ment and leveling phase, a black space was noted.Shorter and more incisally positioned interproximal con-tacts and divergent or triangular-shaped crown formsare associated with posttreatment open gingival embra-sures.13 Grinding the mesial surface could be an optionto correct this unesthetic problem, but the patient re-fused, since the mesiodistal width of the maxillary lateralincisors had been narrowed already. So, the general den-tist, who restored the lateral incisor, preferred inclinationof the left lateral incisor toward the distal aspect to im-prove the profile of the restoration.

The proximity between the maxillary first and secondpremolars occurred because of the necessity for a slightmesial rotation of the first premolars to prevent eccentriccontact during lateral excursive mandibular movements.Since the buccolingual width of the premolar root isgreater than the mesiodistal dimension, some root prox-imity can occur.

The surgeon inserted a premolar implant into the firstmolar site, because of the bone defect. To obtain goodintercuspation, it was necessary to tip the mandibularleft second premolar, which caused the proximity be-tween the mandibular left first and second premolarroots.

These root proximities were not irrelevant. Rootproximity can affect the risk for periodontitis, as mani-fested by progressive alveolar bone loss, by limitingaccess for personal oral hygiene or professional clean-ing.14 Kim et al15 observed that there was no clinicallyrelevant association between the interradicular distanceof more than 0.8 to 1.0 mm and alveolar bone loss. How-ever, if the interradicular distance is less than 0.8 mm,there is a moderately increased risk for loss of alveolarbone. In periodontal patients, root proximity was most


often encountered in the coronal portion of the root,whereas subjects without periodontal disease had moreroot proximity in the apical part where it is less critical.16

So, in these areas of root proximities, special plaque andcalculus control care was recommended to prevent pro-gressive alveolar bone loss.

The extraction of canines has long been regarded asa compromise. In unusual circumstances, however, ca-nine extraction is a viable option that satisfies the majortreatment goals of esthetics, health, function, and stabil-ity.17 The attempt to move a dilacerated and obliquelypositioned maxillary right canine could produce disas-trous side effects such as lateral incisor root resorption.The replacement of the maxillary canines with premolarsto establish group functional occlusion was already de-scribed.17 In a review article, Rinchuse et al18 concludedthat a single type of functional occlusion was not prev-alent in nature. The belief that canine-protected occlu-sion is the optimal type of functional occlusion fororthodontic patients is unsupported by evidence-basedliterature. Moreover, canine-protected occlusion mightbe merely one of several possible optimal functional oc-clusion types for orthodontic patients. Group functionalocclusion (with no interferences) appears to be accept-able, depending on the patient’s characteristics. The sta-bility and longevity of canine-protected occlusion wereconsidered questionable. Consideration of the patient’schewing pattern, craniofacial morphology, static occlu-sion, current oral health status, and parafunctionalhabits might provide important and relevant informa-tion about the most suitable functional occlusion type.But there is a lack of information from long-term studiesconsidering the premolar periodontal status with thistype of occlusion.

A potential side effect after space closure of an atro-phic mandibular first molar extraction site is space re-opening. After appliance removal, a stainless steel0.016-in wire was bonded as a retainer from the man-dibular right and left second molars to the secondpremolars for about 3 months to prevent space reopen-ing. After that, the general dentist requested that the re-tainer be removed to restore the second premolars. Theinterproximal contact points were not tight, but the pa-tient had no discomfort; after 8 months, the space clo-sure seemed to be stable. Continuous clinical andperiapical radiographic monitoring was recommended.

CONCLUSIONS

This case report shows that space closure of missingmolars with atrophic interradicular bone should be con-sidered as a potential solution. However, precise controlof tooth movement during closure of extraction spaces


878 Saga et al

in 3 dimensions is important in meeting treatment goals.The modified helical loop is a simple and efficientorthodontic technique of closing the space without me-sial or lingual tipping, and rotation of molars by usingthe same arch.

REFERENCES

1. Proffit WR, Fields HW Jr, Sarver DM. Contemporary orthodontics.St Louis: Mosby; 2007.

2. Kuhlberg AJ, Burstone CJ. T-loop position and anchorage control.Am J Orthod Dentofacial Orthop 1997;112:12-8.

3. Nagaraj K, Upadhyay M, Yadav S. Titanium screw anchorage forprotraction of mandibular second molars into first molar extrac-tion sites. Am J Orthod Dentofacial Orthop 2008;134:583-91.

4. Chae J, Kim S. Running loop in unusual molar extraction treat-ment. Am J Orthod Dentofacial Orthop 2007;132:528-39.

5. Stepovich ML. A clinical study on closing edentulous spaces in themandible. Angle Orthod 1979;49:227-33.

6. Hom BM, Turley PK. The effects of space closure of the mandibularfirst molar area in adults. Am J Orthod 1984;85:457-69.

7. Kessler M. Interrelationships between orthodontics and periodon-tics. Am J Orthod 1976;70:154-72.

8. Zachrisson BU. Implant site development by horizontal toothmovement. World J Orthod 2001;4:266-72.

9. Carvalho RS, Nelson D, Kelderman H, Wise R. Guided bone regen-eration to repair an osseous defect. Am J Orthod DentofacialOrthop 2003;123:455-67.


10. Spear FM, Mathews DM, Kokich VG. Interdisciplinary man-agement of single-tooth implants. Semin Orthod 1997;3:45-72.

11. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the useof oral implants in adolescents: a 10-year follow-up study. Eur JOrthod 2001;23:715-31.

12. Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom J,Hallen O, et al. Osseointegrated implants in the treatment of theedentulous jaw. Experience from a 10-year period. Scand J PlastReconstr Surg Suppl 1977;16:1-132.

13. Kokich VG. Esthetics: the orthodontic-periodontic restorative con-nection. Semin Orthod 1996;2:21-30.

14. Smukler H, Nager MC, Tolmie PC. Interproximal tooth morphologyand its effect on plaque removal. Quintessence Int 1989;20:249-55.

15. Kim T, Miyamoto T, Nunn ME, Garcia RI, Dietrich T. Root proxim-ity as a risk factor for progression of alveolar bone loss: the Vet-erans Affairs Dental Longitudinal Study. J Periodontol 2008;79:654-9.

16. Vermylen K, De Quincey GN, Wolffe GN, van ’t Hof MA,Renggli HH. Root proximity as a risk marker for periodontaldisease: a case-control study. J Clin Periodontol 2005;32:260-5.

17. Schach RT. Treatment of a Class II, Division 1, malocclusion withthe extraction of maxillary canines and mandibular first premolars.Am J Orthod Dentofacial Orthop 2000;117:459-64.

18. Rinchuse DJ, Kandasamy S, Sciote J. A contemporary andevidence-based view of canine protected occlusion. Am J OrthodDentofacial Orthop 2007;132:90-102.


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