The center of resistance of anterior teeth during intrusion using the laser reflection technique and holographic interferometry

Marc M. Vanden Bulcke,* Luc R. Dermaut,** Rohit C. L. Sachdeva,*** and Charles J. Burstone****
Ghent, Belgium, and Farmington, Corm.

The aim of this investigation was to define the location of the center of resistance of various consolidated units of the maxillary anterior dentition using a dry human skull when subject to intrusive forces. The laser reflection technique and the holographic interferometric technique were employed to measure the displacement of the dentition to the applied forces. The units studied consisted of (a) two central incisors, (b) four incisors, and (c) six anterior teeth. The incorporation of the lateral incisors into the upper incisor segment resulted in a small distal shift of the center of resistance (22 mm). However, when the canines were included into this unit, the center of resistance shifted distally by a significantly larger amount (2 7 mm). Increasing the magnitude of intrusive forces applied to the various units appeared to have no effect on the location of the center of resistance.
(AM J ORTHOO DENTOFAC ORTHOP 90: 21 l-220, Key words: Intrusion, 1986.) laser reflection, segment

center of resistance, holography,

he ability to define the location of the center(s) of resistance of biologic structures is of importance in the control of all types of orthodontic movement-for example, the retraction of molars by a headgear or the intrusion of incisors. The term center of resistance is sometimes confused with the terms center of gravity, center of mass, and center of rotation. r2-7 In a free body, movement is determined by the direction and point of application of the acting force with respect to the center of mass of the object. A force that has its point of application at the center of mass or a series of forces of which the resultant passes through the center of mass will lead to translation of the object. If an object is restrained-for instance, a tooth or a group of teeth in bony sockets-movement is determined by the direction and point of application of a force with respect to the center of resistance of these bodies. When the applied force or the resultant of a number of applied forces passes through the center
This stody was funded by U.S. Public Health Service Grant DEKl6817, and F.K.O. 33.0083.83, Belgium. *Fkmer Assistant, Orthodontic Department, University of Connecticut; Assistant, orthodontic Department, University of Gbent. **Chairman, Orthodontic Department, University of Ghent. ***Assistant Professor, Orthodontic Department, University of Connecticut. ****Chairman, Orthodontic Department, University of Connecticut.

of resistance, the object will then undergo translation. The resistance to the applied forces generated by the surrounding structures of a restrained group of teeth differs from that of a free body; hence, the point of application of the force (or resultant of multiple forces) that brings about translation of a group of teeth may differ from the center of mass. In the orthodontic literature, the centers of resistance are most often defined on a hypothetical basis or estimated through clinical experience.5 Some confusion arises as distinctions are made between dental and skeletal centers of resistance21 because, relative to the cranial base, both the tooth and bone may displace. The center of rotation is the point around which an object appears to rotate from the initial to final stages of the movement. For translation, the center of rotation is at infinity. Various model systems have been developed to study the location of the center of resistance of the upper anterior teeth by means of laser holography. In a previous study, ribbon-arch sectional wires were used as intrusive mechanisms and tied into Begg brackets. Unfortunately, this system allowed for independent movement of the teeth about their centers of rotations to some extent, making it impossible to define the center of resistance of the whole anterior segment. As a result of this investigation, attempts were made to rigidly consolidate the anterior teeth by use of edgewise brack211

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Flg. 2. Sagittal (A) and frontal (6) views of the splint incorporating four upper incisors. Note the distal extension arm of the splints and the hooks that were the points of application for the intrusive forces.

Fig. 1. Occlusal view of the splints incorporating two upper incisors (a), four upper incisors (b), and six upper anterior teeth (c).

ets with the slots filled with a rectangular wire. Unfortunately, such a system also allowed some independent motion of the teeth. In the present investigation, metal splints were used to rigidly hold the anterior teeth to minimize the individual tooth movements. The number of teeth, the point of force application, and the magnitudes of forces were the controlled variables. To detect the initial movements of the teeth to the applied forces, two laser techniques were used: laser reflection and holography. Forces were applied directly to the splint to simulate the application of an intrusive force system as suggested in the segmented-arch technique.. The intrusive arch proposed by Burstone and Nanda- provides an efficient mechanism to intrude teeth. The point contact established anteriorly enables the clinician to place intrusive forces on the anterior segment without erratic force systems coming into play. The objective of this study was to determine the location of the center of resistance for different rigid

units of the anterior maxillary dentition when intrusive forces were applied to them. The direction of pure intrusion was defined as a vertical displacement perpendicular to the occlusal plane. The center of resistance for this study was defined as the point or the zone through which an intrusive force when applied causes pure intrusion (translation) of the selected group of anterior teeth as observed from the lateral (sagittal) view.
MATERIALS AND METHODS

The experiments were performed on a dry human skull presenting with a full complement of dentition and a symmetric dental arch. The upper central incisors were inclined at 112 to the palatal plane, and 105 to the sella-nasion plane. To ensure maximum skull stabilization, the cranium was embedded in hard stone within 5 mm of the maxillozygomatic sutures; this assembly was then fixed to a solid support. Araldit 208, displaying elastic properties somewhat similar to the periodontium (Dijkman, 196913), was used to fix the teeth into the sockets. A catalyst/acrylic proportion of l/IO was used to accelerate setting time. Silicone impressions of the test skull dentition were taken, working models made, and wax models for the anterior

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Table I. Displacement values for the two-, four-, and six-teeth segments applying intrusive forces of 50 g,

100 g, and 200 g among points a to f 50 g

Loading position
Two-teeth a b
C

using the laser reflection technique l@g

SD
2.69 0.40 1.11 0.78 1.57 0.74 0.62 0.80 0.61 1.83 0.35 1.12 0.53 0.42 1.25

2008
SD
1.16 0.84 2.53 0.62 1.15 0.62 1.41 1.71 0.92 0.70 1.51 0.95 1.84 0.29 0.62 0.79

Displacement*
displacements + 14.0 + 10.3 t4.2 -1.4 - 15.0 - 27.2

Displacement*
+31.1 +21.7 + 10.6 -6.2 -34.3 -57.7 + 17.0 + 12.0 +6.8 -6.5 - 10.8 +8.9 +5.3 +3.8 + 1.4 - 1.5 with the traveling microscope.

Displacement*
+49..5 +38.6 + 16.5 -11.5 -56.4 - 10.1 +27.8 +20.5 + 14.8 +1 - 10.9 - 18.8 + 17.6 + 14.7 + 10.4 +3.4 -2.6

SD
2.07 0.91 0.66 0.83 1.23 2.29 1.25 1.07 0.48 0.84 0.74 1.27 1.11 0.84 1.27 1.17 0.70

segment

d e f Four-teeth a b
C

segment

displacements +8.3 +5.4 +3.6 -2.9 -5.1

d e f Six-teeth a b
C

segment

displacements +4.2 +2.6 + 1.3 -0.9

d e f *Displacement of speckle measured

in tenths

of millimeters

sjplints fabricated. The splints weie cast in chromiumcobalt alloy. Three splints were fabricated to fit the different consolidated units under study (two, four, and six anterior teeth, Fig. 1). The splints were fabricated so that their distal ends extended to the second premolars. The splints were rigidly cemented to the teeth with zinc oxyphosphate. A small aluminum plate (1.5 x 3 cm) was fixed at their midpoints, perpendicular to the occlusal plane. These small plates were used to measure the initial displacements of the splints following loading. V-shaped hooks positioned along the splints served as points of attachment for force application (Fig. 2, A and B). Two forces, equivalent in magnitude and perpendicular to the occlusal plane, weie generated by dead weights and applied at points symmetric to the midline. At the midpoint of the segment (that is, between the two central incisors), only a single force was applied. The splints embracing two, four, and six teeth were numbered 1, 2, and 3, respectively. The loading positions were indicated with the letters a, b, c, d, e, and f. For loading position a, the force was applied between the central incisors; for position b, between the central and lateral incisors; for position c, between the lateral incisors and canines; for position d, between the canines and first premolars; for position

e, between the first and second premolars; and for position f, distal tq the second premolar (Fig. 2, B). Two laser measuring techniques were used: a holographic interferometric technique and a laser reflection technique. An argon laser, Spectra Physics model 165 ,* with 265 power supply (wavelength 6,328 A) was used. The skull and the optical components were positioned on a vibration-free table to allow both registration techniques to be used with minimal rearrangement of the technical equipment. For the holographic registration, the double exposure technique as described in the literature2.4-9 was used. The pictures were registered on holotest plates by Agfa-Gevaert (4 X 5 X 0.060 inch HD BE56).t For practical reasons, the skull was loaded during the first half of the exposure time and not loaded during the second half. Frontal and occlusal holograms were recorded for each of the splints and successive loads of 50 g, 100 g, and 200 g were applied. The technique provides an overall impression of the individual displacements of the craniofacial components (including the dentoalveolar complex) to applied forces. The number of fringes on the exposed plate is a measure
I

*Spectra-Physics, Inc.. San Jose, Calif. tAgfa-Gevaelt Rex, Inc., Secaucus, N.J.

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Figs. 3 through 5. Graphic representations of the results obtained using the laser reflection technique. Horitonial axis-displacement of speckle measured in tenths of millimeters. Vertical axis-points of force application. Fig. 3 (shown above). Two-teeth segment with applied intrusive loads of 50 g, 100 g, and 200 g.

of the magnitude of the displacement. Also, rigid-body motion of the skull and its stabilizing unit may be detected using this method. This is important because any displacement of the skull to the applied forces may influence the interpretation of the results. The holographic technique was used to substantiate the results obtained with the laser reflection technique for the various experimental investigations performed. It is important to note that the holograms do not give any indication of the direction of displacement-that is, if the motion is away or toward the observer. However, the laser reflection technique is effective in providing such information. For the experimental investigations involving the use of the laser reflection technique,** the laser beam was direcied onto the middle of the aluminum plate (fixed perpendicular to the metal splint). The reflected beam was intercepted by a microscope (magnification x 30). When looking through the objective, a well recognizable speckle was brought to the center of the hairline by adjusting the objective of the microscope. The splint was then loaded, and the direction and amount of displacement of the reflected speckle were noted. An upward movement of the speckle (downward when observed through the objective of the microscope) indicated a counterclockwise rotation of the splint. A downward movement of the speckle (upward when observed through the objective of the microscope) indicated a clockwise rotation of the anterior segment. No inotion of the speckle on applying the intrusive force indicated pure intrusion. It was therefore inferred

from this that the intrusive force acted through the center of resistance of the unit. Measures for all centers of resistance were determined from a plane parallel to the midsagittal plane.
ANALYSIS OF THE MEASURING RESULTS OBTAINED WITH THE LASER REFLECTION TECHNIQUE

Intrusive loads were applied to the three splints and six values for displacement of the speckle were recorded for a given load. Means and standard deviations of the measures of speckle displacement appear in Table I. For various loading conditions of the splint, the speckle was observed to move upward or downward. These displacements were assigned a positive or negative sign that corresponded to counterclockwise or clockwise rotation of the splint, respectively. In Table I, the displacement values are recorded for the two-, four-, and six-teeth segments for intrusive forces of 50 g, 100 g, and 200 g loaded at points between a and f. The results, are also presented graphically in Figs. 3 through 5. On the vertical axes are plotted the points of application of the intrusive force and on the horizontal axes the displacement measures of the splint. A positive abscissa represents a counterclockwise rotation and a negative abscissa a clockwise rotation.
Two-central-incisors segment: Splint 1 (Fig. 3)

When 50 g of an intrusive load was placed on the two-central-incisors segment through positions a to f, displacement occurred. Counterclockwise rotation

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Fig. 4. Four-teeth see Fig. 3.)

segment with applied intrusive loads of 50 g, 100 g, and 200 9. (For complete legend,

was produced at loading positions a, b, and c, with clockwise rotation at the loading positions d, e, and f. The point of intersection of the graph with the vertical axis corresponded to the point of force application that induced no rotation; by definition, the intrusive forces go through the center of resistance. This loading position lies between cl and d; nearer to the latter than the former. It may be concluded that if the rigidity of the segment is maintained, an intrusive force placed distal to the canine eminence will result in pure intrusion of the central incisors with respect to the cranium. When the force levels applied were raised to 100 g and 200 g, the respective graphs intersected the vertical axes at the same point as that of the 50 g graph. This indicates that the center of resistance does not change with increasing force magnitude in this particular model system. Forces applied at positions mesial to the center of resistance created rotations of much greater magnitude than those applied distal to the center of resistance. Four-incisors segment: Splint 2 (Fig. 4)

Fig. 5. Six-teeth segment with applied intrusive loads of 50 g, 100 g, and 200 g. (For complete legend, see Fig. 3.)

magnitudes of the rotations created by intrusive loads applied mesial or distal to the loading position d. Six-anterior-teeth segment: Splint 3 (Fig. 5)

When the four incisors were segmented and an intrusive force of 100 g was applied, counterclockwise rotation was observed for the loading positions a, b, and c, with clockwise rotation for the loading positions e and f. For the loading position d, pure intrusion was observed. An intrusive force applied between the canine and the first premolars induced pure intrusion of all four incisors. Varying the amount of the force (50 to 200 g) did not change the location of the center of resistance. No obvious differences were observed between the

When an intrusive force of 200 g was placed on the six anterior teeth at positions a through f, rotations occurred. Counterclockwise rotation was observed at the loading positions a, b, c, and d, with clockwise rotation at the loading position f. At position e, the applied force passed through the center of resistance of the six-teeth segment since no rotation was observed. A load of 100 g did not change the location of the

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Fig. 6. Frontal holograms with two-teeth segment, applied intrusive loads of 50 g (A), 100 g (B), and
200 g (C).

Table II. Comparison between the number of fringe patterns observed on the hologram and displacement values obtained by the laser reflection technique for similar loading condition for the two-incisor segment at loading position a
Intrusive force 50 g 1mg 2mg *Displacement of speckle traveling microscope. (Fig. Hologram 6, A through 7 fringes 16 fringes 34 fringes measured Laser C) rejlection value* 14.0 31.1 49.5 in tenths of millimeters with the

center of resistance. For an intrusive force of 50 g applied at a position between d and f, neither positive nor negative rotation occurred. The force was obviously too light.
ANALYSIS OF THE HOLOGRAPHIC RECORDS

Frontal and palatal views were taken of each of the three splints loaded at the six loading positions discussed previously. The forces applied were those commonly suggested for use in clinical practice-50 g for splint 1, 100 g for splint 2, and 200 g for splint 3. For the purpose of this study, only the centers of resistance located from the frontal views of the holograms were of significance. The findings on the palatal view holograms were in agreement with the findings of the fron-

tal views and the results obtained by the laser reflection method; therefore, the palatal views will not be discussed. The interpretation of the holograms was based on the relationships of the various fringe patterns observed on the aluminum plates. When the distances between the fringes on the plates were the same, this indicated pure rotational movement. When the fringes were parallel to the incisal edge of the tooth, the displacement may be interpreted as clockwise or counterclockwise rotation. However, the distinction between the posterior or anterior rotations cannot be read from the hologram. The rigid body motion of the skull was tested with splint 1 and intrusive forces of 50 g, 100 g, and 200 g applied between the central incisors (Fig. 6, A through C). Increasing the amount of force caused no change in the direction of the fringes. However, the number of fringes observed increased linearly with the application of increased levels of force. This finding related well with the measures obtained by the laser reflection technique (Table II). Slight bone deformation was visible with loads of 50 g (one fringe). This deformation increased as the applied load changed from 100 g (two fringes) to 200 g (4 fringes). However, the zygomatic structures appeared to remain unaffected.
Two-upper-jncisors segment: Splint 1 (Fig. 7)

An intrusive force of 50 g was applied and placed symmetrically for all possible positions on the splint

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Fig. 7. Frontal holograms with two-teeth segment, applied intrusive load of 50 g. A through F, Loading positions a through f.

(that is, through positions a to f ). It was observed that the density of the fringe pattern decreased gradually from the loading positions a through c and increased again from loading positions d through f. The fringe patterns in the regions co and d displayed similar densities; however, the loading directions were distinctly different. The holograms in Fig. 7, C and D did not give any indication as to the direction in which the rotation took place. The displacement values obtained by means of the laser reflection technique and displayed in Table I demonstrate that the decreasing fringe patterns corresponded to the decreasing coun-

terclockwise rotations of the splint and that the increasing fringe patterns corresponded to the increasing clockwise rotations, thus definitely suggesting that the splint observed on the hologram in Fig. 7, C displaced in a counterclockwise direction and on the hologram in Fig. 7, D in a clockwise direction. Four-incisors segment: Splint 2

The splint connected the four incisors and the amount of intrusive force applied was 100 g. Intrusive loads were applied at positions a (between the central incisors) through f (distal to the second pre-

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Fig. 8. Graphic representation of the results obtained using the laser reflection technique for the twoteeth, four-teeth, and six-teeth segments with respectively applied loads of 50 g, 100 g, and 200 g.

molars). It could be observed that the density of the fringe patterns decreased from the loading positions a through c. At position d, no fringes were observed on the aluminum plate; this implies that the intrusive force passed through the center of resistance. The number of fringes increased from the loading positions e through f. These findings concurred with the findings obtained using the laser reflection technique listed in Table I and displayed graphically in Fig. 4.
Six-anterior-teeth segment: Splint 3

The splint connected the six upper anterior teeth and the magnitude of the applied force ~8s 200 g. Intrusive forces were applied at all positions from a through f. The density of the fringe pattern decreased from loading positions a to d. At position e, no fringes were seen. A fringe pattern was visible at loading position f. This corresponded to the findings of the laser reflection study. Only with intrusive forces applied distal to the second premolars could pure vertical displacement of the splint be achieved.
DISCUSSION

The dentition and bone comprise a functional unit responsive to orthodontic forces. Bone deformation can certainly influence the location of the center of resistance relative to the cranium. Therefore, it is important to recognize that the center of resistance of the dentition cannot be thought of in isolation of its anatomic relationships in any study of this nature. The laser reflection and holographic interferometric

techniques are very useful tools to measure the initial displacements of a body subjected to an applied load. The results obtained with the laser reflection method clearly demonstrate that varying the levels of the intrusive forces applied to the anterior teeth causes little, if any, shift of the center of resistance for a rigidly connected segment (irrespective of the number of symmetric units of the upper anterior dentition consolidated). The application of greater magnitudes of intrusive forces at the same point of application should, as expected, result in similar displacement characteristics of the dentoskeletal unit; however, in practice the greatest limitation in applying high-force levels to the dentition is imposed by the biologic response to such forces, which may comprise tissue destruction, root resorption, and possible loss of anchorage. The holographic study, independent of the laser reflection technique, demonstrated the same location for the centers of resistance for the various units studied. In addition, the posterior movement of the centers of resistance as a result of the incorporation of more teeth into the splint was seen using both techniques. This suggests that either of the methods described here may be used reliably to study tooth displacement. Fig. 8 demonstrates the results obtained using the laser reflection technique for the two-teeth, four-teeth, and six-teeth segments with applied loads of 50 g, 100 g, and 200 g, respectively. Displacements of speckles are plotted on the horizontal axis; points of force application are plotted on the vertical axis. A positive figure on the horizontal axis refers to a counterclock-

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wise rotation of the anterior unit and a negative figure to a clockwise rotation. The intersection points of the graph with the vertical axis refer to the points of application of forces that result in a vertical translation of the unit. The center of resistance displaces posteriorly as more teeth are incorporated into the segment. The shift between the two-teeth unit and the four-teeth unit is 22 mm. However, substantial posterior shift of the center of resistance is seen when the canines are added to the four-teeth unit (7 mm = a premolar width). This may be caused by the bending of the bony structures surrounding these teeth. It is realized that the center of resistance of a body can vary as a function of the various anatomic relationships of the dentoskeletal unit and biologic factors such as the physiologic reaction of living tissue to forces, the degree of humidity of bone, changes in axial inclination of the anterior teeth, and varying tooth sizes. In all probability, these factors may have some effect on the position of the center of resistance and were excluded from this experiment. However, the importance of this type of research lies in the clues it may provide in establishing the nature of the response of the dentition to applied forces when loading conditions and anatomy are controlled. The application of the optimal force system in orthodontics may then become a reality if the results of in vitro studies are correlated with in vivo animal and clinical studies.
SUMMARY AND CONCLUSIONS

incisors, the center of resistance was situated on a projection line perpendicular to the occlusal plane between the canines and first premolars. 3. For a rigid anterior segment that included the six anterior teeth, the center of resistance was situated on a projection line perpendicular to the occlusal plane distal to the first premolar. 4. The centers of resistance of the anterior segments incorporating two or four anterior teeth were within If: 2 mm of each other. However, inclusion of the canines in the anterior segment resulted in the center of resistance moving distally by approximately one premolar width (7 mm). This effect may have been the result of the resistance of bony structures at the level of the canines and some bending of the maxillary complex as was observed on the holograms. 5. No appreciable shift in the location of the centers of resistance of the various segments studied was detected as varying magnitudes of intrusive force were applied.

The authors would like to thank ProfessorP. Boone and J. Morton for their valuable suggestionsduring the courseof this study, and Barbra Rich for her secretarialassistance.
REFERENCES

1. DuterlooHS: Extra-orale traktie.University of Groningen, The

Netherlands, 1981. 2. Hocevar R: Understanding, planning, and managing tooth movement: Orthodontic force system theory. AM J ORTHOD 80: 457477, 1981. 3. Christiansen RL, Burstone CJ: Centers of rotation within the periodontal space. AM J ORTHOD 55: 353-368, 1969. 4. Nikolai RJ: Analytical mechanics and analysis of orthodontic tooth movements. AM J ORTHOD 82: 764-766, 1982. 5. Burstone CJ: Application of bioengineering to clinical orthodontics. In Graber TM, Swain BF (editors): Orthodontics, current principles and techniques. St. Louis, 1985, The C. V. Mosby Company, pp 193-229. 6. Burstone CJ, Pryputniewicz RJ: Holographic determination of centers of rotation produced by orthodontic forces. AM J ORTHOD 77: 396-409, 1980. 7. Smith RJ, Burstone CJ: Mechanics of tooth movement. AM J
ORTHOD 85: 294-307, 1984.

The goal of this study was to define the location of the centers of resistance of various units of the anterior segments to applied intrusive loads by means of both the laser reflection and holographic interferometry techniques. Tooth displacements were measured on a dry human skull. One must be judicious in directly applying the results obtained from investigations using dry human skulls to study the displacement characteristics of the dentoskeletal unit in the clinical situation. However, such models have the advantage of simulating the in vivo system; for instance, the relationship of the various anatomic structures are maintained intact and, more important, force variables can be controlled, keeping the anatomic geometries the same. 1. For an anterior segment comprising two central incisors, the center of resistance was located on a projection line parallel to the midsagittal plane on a point situated at the distal half of the canines. 2. For an anterior segment that included the four

8. Liu SV, Herschleb CW: Controlled movement of maxillary incisors in the Begg technique. AM J ORTHOD 80: 300-315, 1981. 9. Burstone CJ: The rationale of the segmented arch. AM J ORTHOD 11: 805-822, 1962. 10. Burstone CJ: The mechanics of the segmented arch technique. Angle Orthod 36: 99-120, 1966. 11. Nanda R: The differential diagnosis and treatment of excessive overbite. Dent Clin North Am 25: 69-84, 1981. 12. Dermaut LR, Vanden Bulcke MM: Evaluation of intrusive mechanics of the type segmental arch on a macerated human skull using the laser reflection technique and holographic interferometry. AM J ORTHOD 89: 251-263, 1986. 13. Dijkman JFP: Distribution of forces in orthodontic treatment. Thesis, University of Nijmegen, 1969.

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14. Dermaut LR, Beerden L: The effects of Class II elastic force on a dry skull measured by holographic interferometry. AM J ORTHOD79: 296-304, 1981. 15. Pavlin D, Vukicevic D: Mechanical reactions of facial skeleton to maxillary expansion determined by laser holography. AM J ORTHOD83: 498-507, 1984. 16. Pryputniewicz RJ, Burstone CJ: The effect of time and force magnitude on orthodontic tooth movement. J Dent Res 58: 17541764, 1979. 17. Kragt G: Initial dentofacial orthopedic reactions. A holographic study. Thesis, University of Groningen, 198 1. 18. Wedendal PR, Bjelckhagen HI: Dental holographic interferometry in vivo, utilizing a ruby laser system. Acta Odontol Stand 32: 345-356, 1974. 19. Burstone CJ, Pryputniewicz RJ, Bowley WW: Holographic measurement of tooth mobility in three dimensions. J Periont Res 13: 283-294, 1978. 20. Ryden H: The laser reflection method: Measurements of tooth movements. Thesis, University of Stockholm, 1980.

21 Stockli P, Teuscher U: Combined activator headgear orthopedics. In Graber TM, Swain BF (editors): Orthodontics, current principles and techniques. St. Louis, 1985, The C. V. Mosby Company.
Retwint requests to:

Marc Vanden Bulcke Kliniek voor Tand-, Mond- en Kaakziekten Afdeling Orthodontie Akademisch Ziekenhuis De Pintelaan 135 B-9000 Ghent Belgium Rohit Sachdeva Department of Orthodontics University of Connecticut Health Center Farmington, CT 06032