OBJECTIVES: To investigate the effectiveness of mini-implant (MI)-facilitated micro-osteoperforations (MOPs) in accelerating mandibular anterior teeth alignment. MATERIALS AND METHODS: Thirty teenage patients with mandibular crowding (Little's irregularity index between 4 and 6 mm) were randomly allocated to either “experimental” group (micro-osteoperforation assisted alignment) or “control” group (conventional orthodontics). Blinding was done at the data analysis stages. Six MOPs were performed using MI on the labial aspect in the mandibular anterior region. The primary outcome was the overall treatment time needed to complete alignment of mandibular anterior teeth. The secondary outcomes were to compare the marginal bone height loss and volumetric root resorption around mandibular incisors along with subject's perception of pain, comfort and satisfaction. RESULTS: There was statistically significant difference in the total treatment duration for complete alignment of mandibular incisors. The completion of cases in experimental group was 43.93% times faster than the control group. There were no statistically significant differences in volumetric root resorption and marginal alveolar bone height loss around mandibular incisors as well as pain perception between the two groups. CONCLUSIONS: MI-facilitated MOPs accelerated tooth movement significantly upto nine weeks without any significant pain and discomfort, with no increase in root resorption and marginal alveolar bone height loss.

OBJECTIVES: To compare the accuracy of the linear measurements made on pre- and posttreatment three-dimensional (3D) scanned digital models with conventional plaster study models. MATERIALS AND METHODS: The study was conducted on pre- and posttreatment study models of 132 patients. A 3D model scanner was used to scan the plaster models to form 3D digital models. The measurements were made on the plaster models using digital Vernier calipers, and the 3D digital models were assessed for similar measurement using a software of the model scanner. The intraclass correlation for intraoperator error showed good correlations between the measurements made on conventional plaster models and digital models. RESULTS: Although the comparison of the linear measurements made by conventional and digital methods on both pre- and posttreatment study models using intraclass coefficient showed a good correlation, analysis of variance showed significant mean differences in the measurements of multiple variables in both the groups. The number of variables showing significant differences was more in the pretreatment group. The measurements obtained by Vernier calipers were generally higher than those of scanned pre- and posttreatment study models. CONCLUSION: The linear measurements made by conventional and digital methods showed statistically significant mean differences. The accuracy of recording can be affected by the severity of pretreatment malocclusion, but the deviations were not large enough to contradict the use of the digital models for orthodontic records.

OBJECTIVES: To evaluate and compare the effect of different enamel deproteinizing agents on topographic features of enamel and shear bond strength before acid etching. MATERIALS AND METHOD: In total, 120 sound human maxillary premolars were taken and divided into three groups: Group 1 control (37% phosphoric acid (H₃PO₄), Group 2, (5.25% Sodium Hypochlorite (NaOCl)+ 37% H₃PO_4, and Group 3, (10% Papain gel + 37% H₃PO₄). These groups were further divided into A and B subgroups. In subgroups 1A, 2A, and 3A (n30) topographic features were evaluated using Scanning electron microscope (SEM) at different magnifications. Insub-groups 1B, 2B, and 3B (n90) metal brackets were bonded with Transbond™ XT, and all the samples were subjected for Shear Bond Strength (SBS) evaluation using universal testing machineat a cross speed of 0.5 mm²/min. The failure mode was analyzed using adhesive remnant index (ARI).Statistical analysis was done using one-way ANOVA for the shear bond strength, and Kruskal-Wallis test followed by Mann-Whitneywas performed for ARI scores. RESULTS: SEM showed predominance of type 3 etching pattern in control Group (1A) and type 1 and type 2 in deproteinizedGroups (2A and 3A).Mean values of shear bond strength showed statistically significant differences between evaluated groups (P < 0.005).The lowest and highest shear bond strength was attributed to Group 1B (Control) and 3B (10% papain gel), respectively. Statisticallysignificant differences were noted for the mean ARI scores between control and deproteinized group (P < 0.05). CONCLUSION: 10% papain geland 5.25% NaOCl can be used as deproteinizing agents on enamel surface before acid etchingto enhance the shear bond strength of orthodontic brackets.

OBJECTIVES: To investigate pain intensity, interleukin-1β and prostaglandin E₂ values in saliva during initial orthodontic treatment among varying age groups and their correlation between these mediators. MATERIALS AND METHODS: Twenty healthy patients distributed equally in age and gender groups were chosen. Unstimulated saliva was collected before the placement of orthodontic fixed appliance (T₀), 1 hour after the placement of the appliance with 0.014” nickel titanium archwire (T₁), 1 month after the first visit (T₂), and 1 hour after the placement of 0.016” nickel titanium archwire (T₃). The saliva samples were then analyzed for prostaglandin E₂ and interleukin-1β using enzyme-linked immunosorbent assay. Pain intensity was measured using a numerical rating scale. RESULTS: Prostaglandin E₂ and interleukin-1β levels had increased at T₁ followed by a drop at T₂ and a subsequent increase at T₃. The prostaglandin E₂ and interleukin-1β levels were higher in adults than children. There was an insignificant correlation between the interleukin-1β and prostaglandin E₂ changes in all the patients. No significant differences were seen in pain scores between adults and children. Insignificant correlation was seen between pain scores and prostaglandin E₂ and interleukin-1β. CONCLUSION: Prostaglandin E₂ and interleukin-1β can be detected in saliva and are increased in during the initial orthodontic treatment but are higher in adults than children. Pain intensity was not significantly different between adults and children.

OBJECTIVES: Previous reports have shown that high-frequency vibration can increase bone remodeling and accelerate tooth movement. The aim of this study was to evaluate the effects of high-frequency vibration on treatment phase tooth movement, and post-treatment bone density at initiation of retention, with cone-beam computed tomography (CBCT). MATERIALS AND METHODS: Thirty patients with initial Class I skeletal relationships, initial minimum-moderate crowding (3–5 mm), treated to completion with clear aligners and adjunctive high-frequency vibration, (HFV group) or no vibration, (Control group) were evaluated. The patients were instructed to change aligners as soon as they become loose. Changes in bone density associated with orthodontic treatment were evaluated using i-CAT cone-beam computed tomography (CBCT) and InVivo Anatomage^® software to quantify density using Hounsfield units (HU) between treated teeth in 10 different regions. HU values were averaged and compared against baseline (T1) and between the groups at initiation of retention (T2). RESULTS: The average time for aligner change was 5.2 days in the HFV group, and 8.7 days in the control group (P = 0.0001). There was significant T1 to T2 increase of HU values in the upper arch (P = 0.0001) and the lower arch (P = 0.008) in the HFV group. There was no significant change in average HU values in the upper (P = 0.83) or lower arches (P = 0.33) in the control group. The intergroup comparison revealed a significant difference in the upper, (P = 0.0001) and lower arches (P = 0.007). CONCLUSION: High-frequency vibration adjunctive to clear aligners, allowed early aligner changes that led to shorter treatment time in minimum-moderate crowded cases. At initiation of retention, the HFV group demonstrated statistically significant increase as compared with pre-treatment bone density, whereas control subjects showed no significant change from pre-treatment bone density.

OBJECTIVES: This study aimed to evaluate how dental practitioners and laypersons differ in their perception of altered smile aesthetics based on viewing images of a digitally manipulated smile. MATERIALS AND METHODS: A photograph with close to ideal smile characteristics was selected and digitally manipulated to create changes in buccal corridor space (BCS), midline diastema, gingival display, and midline shift. These altered images were rated by two groups: dental practitioners and lay persons using a visual analogue scale. The mean ± standard deviation (SD) of both groups were calculated and the Student's t-test was used to identify any statistically significant differences between the groups. Data analysis was done using the Statistical Package for Social Science (version 23.0; SPSS Inc., Chicago, Illinois, USA). RESULTS: The dentists were more sensitive to changes in the midline shift than laypeople and provided lower scores. There were no significant differences between the two groups when the gingival display alteration was ≤3 mm. However, for gingival display of 4 mm and 5 mm, there was significant difference between the two groups, with dentist rating them poorer as compared with the laypeople (P < 0.001). Dentists were more sensitive than the laypeople for midline diastema of 2 mm and 3 mm (P < 0.001 and P = 0.005 respectively). Changes in the BCS had minimal impact on the overall esthetic score for both the groups. CONCLUSIONS: Perception of smile esthetics differed between dentists and laypersons.

BACKGROUND: This study was undertaken to evaluate the enzyme activity profiles in human saliva and gingival crevicular fluid (GCF) in accelerated tooth movement when compared with normal orthodontic tooth movement (OTM) in extraction cases. MATERIALS AND METHODS: Twenty patients who required premolar extractions were treated with MBT mechanotherapy. They were divided into two equal groups: conventional (Group I) and corticotomy (Group II) which was performed on both the jaw sides before initiating retraction. GCF was collected from mesial and distal aspects of canine before initiation of retraction and at 7^th, 14^th, 21^st, and 28^th days, and then at fifth and sixth weeks and third and sixth months after retraction. A total of 5 mL of unstimulated saliva was collected from the subjects after 90 min of nonoral activity (subjects were refrained from eating and drinking). RESULTS: The results showed that in Group I, the peak of aspartate aminotransferase (AST) and alkaline phosphatase (ALP) enzyme activity occurred on the 14^th day of force application. In Group II, the enzyme activity progressively increased from day 0 to 6 weeks, peaking at the sixth week, and then a decline in enzyme activity was observed on third and sixth months. When ALP and AST activities in GCF and saliva were compared between Groups I and II, no statistically significant difference was observed on days 0, 7, and 14. CONCLUSION: Corticotomy-accelerated tooth movement is a promising technique that has many applications in orthodontic treatment of adults as it helps overcome many of the current limitations of this treatment. The enzymatic activity signifies osteoclastic and osteoblastic activities, so ALP and AST from the saliva and GCF may potentially be used as biomarkers for monitoring corticotomy-assisted OTM.

INTRODUCTION: Motivation for orthodontic treatment among adolescents has been linked with patients' response during treatment. Parents have also been seen to be influencing factors in patient motivation. This study investigates the motivation for orthodontic treatment among patients and their parents/guardians. MATERIALS AND METHODS: Data were obtained from 100 orthodontic children (41 boys, 59 girls), with a mean age of 11.9 years, in the age range of 7–17 years, and with parents/guardians from three public hospitals. Recruitment focused on patients and their parents at their initial screening appointment and those scheduled for regular orthodontic treatment. Data were collected by the use of survey forms for both patients and parents. Data were analyzed using Epi info^TM version 3.5.1. RESULTS: Children were more motivated to have orthodontic treatment than their parents before treatment, however parents showed greater motivation for their children to have orthodontic treatment than did the children during treatment. Children on treatment were less motivated than those who have not started treatment. Using braces was more important to children than their parents. Parents of children on treatment were more motivated for their children to have orthodontic treatment than parents of children who were not yet on treatment. Children undergoing orthodontic treatment were not willing to have extractions as part of their treatment, while parents did not have much objections (P = 0.001). Parents were willing to comply with dietary instructions imposed on their children. (P = 0.45). Pretreatment, children were more willing to brush after meals than the ones undergoing treatment (0.010). CONCLUSION: Parents of children on treatment were more motivated for their children to have orthodontic treatment than parents of children who were not yet on treatment. Children on treatment were less motivated during treatment.

INTRODUCTION: Autotransplantation is a surgical method in which a tooth is repositioned within the same patient. It can be described as a controlled reimplantation of an extracted tooth into a new, surgically prepared socket. The key to success of this treatment is the preservation and regeneration of the periodontal ligament. It is an underutilized technique which, if conducted with a multidisciplinary team, can be an ideal treatment option for patients with failing or missing teeth. OBJECTIVES: The detailed clinical procedures, indications for this technique, and the factors affecting its success are discussed.

OBJECTIVE: To evaluate the incidence of malocclusion and requirement for orthodontic treatment in the Saudi region of Hail city. MATERIALS AND METHODS: 520 Saudi participants between 7 and 12 years from Hail city were used in the research, all of whom were selected using a simple randomization method. For every participant, various malocclusion variables such as molar, canine, and incisor relationship, overjet, overbite, open bite, cross bite, scissor cross bite, and the score for the orthodontic treatment need [Index of Orthodontic Treatment Need (IOTN)] were recorded. A light source was used for examination, in addition to mouth mirrors, a calibrated ruler, and a portable dental chair. RESULTS: The prevalence of class I molar relationship was 70.4%, with class II being 21.3% and class III being 8.3%. As for the incisor relationships, class I was found at a prevalence of 72.5%, class II at 19.8%, and class III at 7.7%. Additionally, the following malocclusion characteristics were also found: deep overbite (>4 mm) (16.2%), increased overjet (>4 mm) (14.4%), posterior cross bite (13.3%), anterior open bite (7.7%), anterior cross bite (5.2%), scissor bite (4%), and posterior open bite (0.6%). A total of 4.4% were identified as requiring orthodontic treatment. Grades 1 and 2 were 25.5% and 58.5%, respectively. There was a significant relationship found between grades 3 and 4, and the anterior open bite, cross bite, and scissor bite. CONCLUSION: This research showed that class I malocclusion was most dominant, followed by classes II and III, respectively. When the Hail city school pupils in the study were assessed for IOTN index, grades 3 and 4 were found to be highly related to anterior open bite, cross bite, and scissor bite.

OBJECTIVE: The aim of this study was to compare the efficiency of canine retraction using modified Marcotte and T-loop retraction springs. MATERIALS AND METHODS: Twenty-four subjects with a treatment plan involving bilateral extractions of upper first premolars were included in the study. A split-mouth design was used to randomly allocate opposite quadrants to either modified Marcotte spring (MS) or T-loop spring (TLS) for canine retraction. Cephalometric radiographs and models were used to measure the rate of canine retraction (primary outcome) and compare the angular/rotational changes in the canines and anchorage loss in molars (secondary outcomes) following retraction. Subjective assessment of pain and discomfort was compared using visual analog scale (VAS). Paired and independent t-tests were used to evaluate changes. RESULTS: The mean amount and rate of retraction of the canine were found to be significantly higher for MS (3.56 ± 0.696 mm and 1.188 ± 0.232 mm, respectively) when compared with TLS (2.125 ± 0.472 mm and 0.71 ± 0.157 mm, respectively). Distopalatal rotation of the canine was also significantly lesser for MS (2.42°±1.868°) than TLS (5.65° ±2.84°, P < 0.001). However, the amount of anchorage loss and canine tipping were significantly higher for MS. Statistically significant higher values in the VAS score for TLS indicated greater discomfort. CONCLUSION: MS exhibited increased rate of retraction and rotation control when compared with TLS during sectional canine retraction. Patient comfort was better for MS as evidenced by the VAS scores. However, the amount of tipping and anchorage loss obtained with MS were significantly higher than TLS.

OBJECTIVE: The aim of this study was to investigate the effect of intraoral conditions and fluoride mouthwashes on mechanical properties and surface characteristics of different types of titanium molybdenum alloy (TMA) wires. MATERIALS AND METHODS: Three types of TMA wires of dimension 0.017” × 0.025” [1. Standard TMA (TMA), 2. ion-implanted, low-friction TMA (LF) and 3. Colored, Honey Dew TMA (HD)] were tested in three conditions as three groups; A) Control (as received), B) No fluoride (following intraoral use without fluoride) and C) Fluoride (following intraoral use with fluoride rinses). Surface roughness was evaluated using 3D Optical Profilometer. Three point bending tests were done to evaluate load deflection characteristics (LDR), ultimate tensile strength (UTS), and Young's modulus (E). Statistical evaluation was done using one-way analysis of variance (ANOVA), Bonferroni multiple comparison, and paired t-tests. RESULTS: Control group TMA exhibited significantly higher surface roughness, peak height, and LDR as well as lower UTS and E when compared to LF and HD (P < 0.001). In nonfluoride group, the surface roughness and LDR increased significantly for all three types of wires (P < 0.001). The UTS and E showed a significant decrease (P < 0.001). Additional use of fluoride mouthwashes (fluoride group) further increased surface roughness and LDR and decreased the UTS and E (P < 0.001). CONCLUSION: The ion-implanted LF/HD varieties had better surface smoothness, lower LDR, higher UTS, and higher E than standard TMA in the control group, pointing towards a better efficiency of these wires. Intraoral conditions significantly increased surface roughness and deteriorated mechanical properties of all types of TMA wires. With the use of daily fluoride mouthwashes, the deterioration was much worse.

OBJECTIVES: To systematically investigate and critically appraise the quality of the currently available literature regarding the morphological, postural, and functional changes observed in individuals following glossectomy. MATERIALS AND METHODS: A search without restrictions in eight databases (including grey literature) and hand searching from inception until March 2018 was performed. Data on morphological, postural, and functional changes after glossectomy were reviewed. Methodological quality was evaluated using the risk of bias in nonrandomized studies of intervention tool. RESULTS: Out of 835 initially identified unique records, only three articles following patients for 1 year after glossectomy fulfilled the selection criteria. Overall, no significant morphological, postural, and functional changes were observed. Only the distance between the dorsum and the nasal line increased and the freeway space decreased significantly. CONCLUSIONS: Overall, no significant differences were noted in the medium term, in terms of dentofacial structures adaptation and tongue function following glossectomy. Further research is warranted in order to elucidate the consequences of the altered oral environment.

OBJECTIVES: Leptin, a polypeptide which is related to body fat regulation, is also found to have a role in the inflammatory reaction. The aim of this study is to assess the concentration of leptin in Gingival Crevicular Fluid (GCF) during orthodontic force application and to correlate its concentration to rate of tooth movement. METHODS: Twenty orthodontic patients (10 males and 10 females) were selected for the study. Leptin concentration was measured at T0, before force application; T1, one hour after force application; T2, one day after force application; T3, one week after force application; T4, one month after force application. GCF was collected using filter paper strips from the distal aspect of gingival sulcus of the right maxillary canine distalized by an active lace-backs of tooth movement was measured on dental casts, before and one month after force application. One-way ANOVA with Bonferroni correction and Pearson's correlation test were used to analyze the data. RESULTS: The mean GCF leptin concentration increased from T0 to T1, rose to a peak at T2, then declined to a minimum value at T3 and then increased to a value at T4, closer to the base line value (T0), and it was statistically significant (P < 0.05). There was positive correlation of the overall mean leptin concentration to rate of tooth movement (correlation coefficient = 0.634). CONCLUSION: There was a biphasic change in GCF leptin concentration during one cycle of orthodontic force application. There was a positive correlation between the GCF leptin concentration and rate of tooth movement.

OBJECTIVES: This study aimed at evaluating the effect of using a 45S5 bioglass paste and a topical fluoride as protective agents against acidic erosion (resembling acidic beverage softdrinks intake) for enamel surrounding orthodontic brackets. MATERIALS AND METHODS: Sample of 21 freshly extracted sound incisor and premolar teeth was randomly divided into three equal groups: a bioglass group (Bioglass) (NovaMin, 5-mm average particle, NovaMin Technology), a Fluoride group (Fluoride) (Gelato APF Gel, Keystone Industries), and a control group (Control). Orthodontic brackets were bonded to the utilized teeth usingMIP (Moisture Insensitive Primer) and Transbond PLUS color change adhesive. All specimens were challenged by 1% citric acid for 18 min. The top enamel surfaces next to the orthodontic brackets were examined by SEM-EDS. Wilcoxon Signed-Rank test was used to compare the area covered by the 45S5 bioglass paste before/after erosion P < 0.05. RESULTS: 45S5 bioglass paste application resulted in the formation of an interaction layer that significantly resisted erosion challenge P < 0.05. The fluoride and control specimens showed signs of erosion of the enamel next to the orthodontic brackets (P < 0.05). CONCLUSION: 45S5 bioglass paste can efficiently protect the enamel surfaces next to orthodontic brackets for acidic erosion challenges.

OBJECTIVES: To determine whether the modification of dental occlusion, without molar extraction, affected the gustatory papillae located in the tongue of growing rats. MATERIALS AND METHODS: Five-week-old male Wistar rats were randomly divided into an anterior bite plate (ABP) group and a control group. Under general anesthesia, ABPs were placed on the occlusal surfaces of the maxillary incisors, while metal caps covered the mandibular incisal edges of the rats in the ABP group. The control group rats underwent a sham operation. The rats in both groups were euthanized 14 days after the procedure. The circumvallate papillae and taste buds were analyzed by immunohistochemical methods, and the fungiform papillae were observed and counted after immersion of the tongue in 1% methylene blue. RESULTS: Two weeks after ABP insertion and mandibular incisal cap placement, the gustatory papillae exhibited morphological and structural changes. The rats in the ABP group had exhibited significantly fewer fungiform papillae, and narrower circumvallate papillae, with greater trench depths, larger trench profile areas, smaller taste bud profile areas, lower ratios of the taste bud profile area to the trench profile area, and more taste buds than those in the control group. CONCLUSIONS: Our findings support the association between occlusal and taste functions and provide a basis for further studies on the gustatory function. In conclusion, loss of molar occlusion, resulting from the ABP and metal cap insertion, altered the peripheral gustatory receptors in the growing rats.

OBJECTIVE: To evaluate the maxillary canine retraction rate and anchorage loss with active and passive self-ligating brackets (SLBs). MATERIALS AND METHODS: The study was conducted on 10 patients whose age ranged from 14–20 years. The patients had minimal to no crowding with a dental protrusion of maxillary incisor that required the extraction of maxillary first premolars and retraction of canines. The maxillary canines had to be in a good alignment and level before treatment to ensure that canine retraction had started from the same point bilaterally. A cone beam computed tomography (CBCT) had been taken for each patient's maxilla before treatment initiation and after complete canine retraction. Using nickel titanium, close-coil spring canine retraction on both sides and the rate of canine movement was measured. RESULTS: The patients were checked every 2 weeks to measure the retraction rate and ensure that a constant force (150 g) was being delivered to both canines. The pre- and post-canine retractions CBCT were superimposed to evaluate the pattern and rate of canine movement and anchorage loss. The result of this study showed no statistically significant difference between the two groups. CONCLUSION: The type of SLB, either active or passive, does not affect the rate or type of canine movement during its retraction in the orthodontic extraction cases, and the anchorage loss of the upper molars was nearly the same in both type.

OBJECTIVE: To evaluate the status of occlusion among school children in city of Abha, Saudi Arabia. MATERIALS AND METHODS: The current study was based on the clinical examination of 1998 Saudis (mean age 14.13 ± 0.99 years) who were randomly selected by a multi-stage random sampling technique from the city of Abha. The occlusal parameters recorded in this study were molar and canine relationships, overbite, overjet, crowding, spacing, anterior open bite, anterior crossbite, posterior crossbite, and scissors bite using gloves, light source, mouth mirror, and ruler. RESULTS: Class I molar relationship was observed in 1219 (61%) of the total sample, while Class II and III molar relationships were observed in 326 (16.3%) and 154 (7.7%), respectively. Class I–III canine relationships were seen in 1255 (62.8%), 231 (11.6%), and 112 (5.6%) of the sample, respectively. Normal overbite was found in 1490 (74.6%) of cases, while 1515 (75.8%) had normal overjet. The most prevalent malocclusion trait was crowding (26.6%), followed by spacing (20.6%), increased overjet (19.5%), increased overbite (19.4%), posterior crossbite (8.5%), and anterior open bite (6.1%). CONCLUSIONS: Crowding was the highest occlusal trait in frequency followed by spacing, increased overjet, and increased overbite. Class I molar and canine relationships, normal overjet, and normal overbite were frequent findings among Saudi adolescents in Abha city.

AIMS: To determine the association and level of agreement between young adults' perception of orthodontic treatment need (subjective need) and the orthodontists' assessment of treatment need (normative objective need). METHODOLOGY: For this study, 670 students [280 males and 390 females; mean age (standard deviation) of 15.32 (1.81) years] were selected from public and private schools from different demographic areas of Jeddah city, Saudi Arabia, and divided into two age groups (12–15 years) and (16–19 years). All the participants were examined, and the Index of Orthodontic Treatment Need (IOTN) components [dental health component (DHC) and aesthetic component (AC)] were recorded. RESULTS: Kappa statistics showed a statistically significant but fair agreement between clinician AC (CAC) and student AC (SAC) assessments in both age groups (k = 0.343 and 0.334, respectively; P < 0.001), whereas Spearman's correlation coefficient showed a statistically significant but moderate association (r = 0.487 and 0.517, respectively; P < 0.001). The degrees of agreement were 76.4% and 76.7% at the no-need and mild-need levels of treatment, respectively. There was a statistically significant but weak association between the subjective and normative needs (SAC and IOTN-DHC) in both age groups (r = 0.336 and 0.360, respectively; P < 0.001). However, the degrees of agreement were 58.9% and 61.5% at the no-need and mild-need levels of treatment, respectively. CONCLUSION: Significant but weak positive association was found between the normative and subjective orthodontic treatment needs, indicating a lack of understanding of the nature of malocclusion and its consequences. Thus, promoting further knowledge and awareness of malocclusion are indicated.