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3.
Medicine (Baltimore) ; 100(8): e24869, 2021 Feb 26.
Artículo en Inglés | MEDLINE | ID: mdl-33663114

RESUMEN

ABSTRACT: Techniques for enhancing the effective space of the mandibular arch are urgently needed. Therefore, this study aimed to perform mandibular expansion in combination with a fixed-appliance technique, with preliminary monitoring by finite element analysis and 3-dimensional cone-beam computed tomography (CBCT).Finite element models were structured according to CBCT images of a 14-year-old girl. The von Mises stress of the alveolar bone and tooth displacement were assessed in different models. The technique was also applied in an 11-year-old boy. CBCT was performed at post-expansion, post-retention, post-treatment and 2 years after treatment. Tooth movement and alveolar bone stress were assessed by the CAD software.Finite element analysis suggested that the teeth tended to stand upright in the buccal side in the expander model compared with the expander-remove model. However, minimum tooth change was observed in the normal model, indicating highest stability. The von Mises stress of the alveolar bone was decreased in the normal model compared with the expander model, suggesting that buccal-inclined teeth could more easily lead to alveolar bone stress than normal ones. Based on CBCT data and the 3D mandibular dentition model fitting, mandibular teeth tended to be upright in the buccal side after retention compared with the post-expansion condition, which somewhat differed from finite element analysis results. Furthermore, dehiscence and fenestration were not observed.This expansion technique is expected to increase the effective space after mandibular expansion and reduce buccal alveolar bone stress.


Asunto(s)
Mandíbula/diagnóstico por imagen , Aparatos Ortodóncicos Fijos , Técnica de Expansión Palatina/instrumentación , Técnicas de Movimiento Dental/métodos , Adolescente , Niño , Tomografía Computarizada de Haz Cónico , Femenino , Humanos , Imagenología Tridimensional , Masculino , Proyectos Piloto
6.
Am J Orthod Dentofacial Orthop ; 159(4): 435-442, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33573896

RESUMEN

INTRODUCTION: The purpose of this reseach was to compare the effects of different periodic periodontal scaling protocols on the periodontal health of adolescents with fixed orthodontic appliances by assessing the aspartate aminotransferase (AST) and alkaline phosphatase (ALP) levels in gingival crevicular fluid and periodontal clinical indexes in a prospective cohort study. METHODS: Forty-eight adolescents were divided into 3 groups according to the interval of periodontal scaling (group A: once a month; group B: once every 3 months; group C: once every 6 months). The AST and ALP levels in the gingival crevicular fluid were measured before orthodontic treatment (T0) and at 1 (T1), 3 (T2), 6 (T3), and 9 (T4) months during orthodontic treatment. Periodontal clinical indexes (plaque index [PI], gingival index [GI], and probing depth) were also assessed. RESULTS: At T2, significantly lower AST and ALP levels were observed in group A than in groups B and C (P <0.05). At T3 and T4, lower AST and ALP levels were detected in groups A and B than in group C (P <0.05), and there was no significant difference between the A and B groups at T4 (P >0.05). At T2, the PI and GI were increased in groups B and C compared with group A, and at T3 and T4, significantly lower PI and GI values were observed in groups A and B than in group C (P <0.05). CONCLUSIONS: Periodontal scaling promotes the oral hygiene of adolescents undergoing fixed orthodontic treatment, and periodontal scaling protocols administered monthly and once every 3 months are better for controlling periodontal health than treatments administered once every 6 months.


Asunto(s)
Higiene Bucal , Aparatos Ortodóncicos Fijos , Adolescente , Índice de Placa Dental , Líquido del Surco Gingival , Humanos , Aparatos Ortodóncicos/efectos adversos , Índice Periodontal , Estudios Prospectivos
7.
Oral Health Prev Dent ; 19(1): 67, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33491380

RESUMEN

PURPOSE: Orthodontic treatment may introduce a risk to the integrity of enamel due to plaque accumulation and colonisation by oral microbes. This prospective cohort study observed the effect of fixed, self-ligating orthodontic appliances on saliva properties and oral microbial flora. Materials and Methods: Thirty adolescent patients were recruited (13 female, 17 male, mean age 13.97 ±â€¯2.07 years). Saliva samples were collected before placement of fixed orthodontic appliances (T0), and 4 (T1) and 12 (T2) weeks later. Salivary pH, flow rate and buffering capacity were recorded. All saliva samples were cultured on agar plates for 2 days. Salivary prevalence of Neisseria spp., streptococci, Staphylococcus aureus, coagulase-negative staphylococci and Candida albicans were assessed. Results: High buffering capacity was reported in 21 patients at T0, 22 patients at T1 and in 28 patients at T2. Saliva flow rate also increased over time (7.08 ml/5 min at T0, 7.93 ml/5 min at T1 and 8.35 ml/5min at T2). Mean pH was 7.63 at T0, 7.67 at T1 and 7.78 at T2. There was no evidence that either pH or the number of colonies of any of the microbial species changed over time. Conclusion: The increased buffering capacity of saliva as well as the salivary flow rate after initial bonding might be protective against the development of dental caries. Current microbial findings indicate that initiation of orthodontic treatment may not be associated with significant changes in oral microbial flora.


Asunto(s)
Caries Dental , Saliva , Adolescente , Niño , Índice de Placa Dental , Femenino , Humanos , Masculino , Aparatos Ortodóncicos , Aparatos Ortodóncicos Fijos/efectos adversos , Estudios Prospectivos
8.
Angle Orthod ; 91(2): 149-156, 2021 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-33434285

RESUMEN

OBJECTIVES: To determine dentoalveolar and skeletal effects produced in mature patients by the Carriere Motion Class III (CM3) appliance followed by fixed appliances. MATERIALS AND METHODS: This retrospective study evaluated 32 patients at three time points: T1 (initial), T2 (removal of CM3), and T3 (posttreatment). Serial cephalograms were traced and digitized, and best-fit regional superimpositions were constructed. Eleven linear and 7 angular variables were measured. The starting forms of the CM3 patients were compared with a sample of untreated subjects with normal occlusions and well-balanced faces. RESULTS: The CM3 phase lasted 6.3 months, followed by a phase of fixed appliances lasting 12.9 months; the total duration of treatment was 19.2 months. Minimal skeletal changes were measured sagittally, with only a slight increase in lower anterior facial height observed during treatment. Most treatment changes were dentoalveolar in nature. Wits appraisal increased 4.0 mm during treatment. The molar relationship improved by 6.0 mm during phase I, a value that rebounded slightly during phase II, resulting in an improvement toward Class I of 4.8 mm. Best-fit regional superimpositions revealed anterior movement of upper molars relative to the maxilla and posterior movement of lower molars relative to the mandible. CONCLUSIONS: The Carriere Motion Class III appliance is an effective and efficient method of resolving occlusal problems in minimally growing Class III patients. Primary treatment effects are dentoalveolar in nature with minimal skeletal alterations.


Asunto(s)
Maloclusión de Angle Clase II , Aparatos Ortodóncicos Funcionales , Adolescente , Adulto , Cefalometría , Humanos , Maloclusión de Angle Clase II/diagnóstico por imagen , Maloclusión de Angle Clase II/terapia , Mandíbula , Maxilar , Diseño de Aparato Ortodóncico , Aparatos Ortodóncicos Fijos , Estudios Retrospectivos
9.
Clin Oral Investig ; 25(3): 1525-1534, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33409688

RESUMEN

OBJECTIVES: Angle Class II malocclusions including a retrognathic mandible are the most frequent orthodontic problems. Both removable and fixed functional appliances can be used for mandibular advancement. Mandibular advancement after treatment with any fixed functional appliance has numerous therapeutic effects, such as stretching of masticatory muscles, ligaments, membranes and surrounding soft tissues, thus causing positional changes of the hyoid bone and epiglottis. This retrospective study investigates and compares treatment effects upon epiglottis- and hyoid bone position and posterior airway space in class II patients who received mandibular advancement through two different cast splint fixed functional appliances. MATERIAL AND METHODS: Two groups of 21 patients each ('Functional Mandibular Advancer' (FMA) and Herbst appliance) were investigated. The same experienced orthodontist performed the treatment in all patients, employing a single-step advancement protocol. The mandible always received initial protrusion into an edge-to-edge position. Conventional lateral cephalograms were available pre-treatment (T1) and immediately after appliance removal (T2) for all patients. The measurements comprised (I) hyoid bone, (II) epiglottis or (III) posterior airway space. Treatment-related changes were analysed with one-sample Student's t tests for intragroup comparisons and independent Student's t tests for intergroup comparisons. Statistical significance was set at p < 0.05. RESULTS: Measurements of the hyoid bone showed mostly increases for both appliances after treatment. Intergroup comparisons were not significant for FMA patients but significant for selected measurements in Herbst appliance patients. Intergroup comparisons showed insignificant changes. The posterior airway space was always insignificantly increased after treatment. The greatest increase was found caudally. Intergroup comparisons showed insignificant changes. CONCLUSIONS: Both fixed functional appliances cause an anterior and caudal displacement of epiglottis and hyoid bone and enlarge the posterior airway space. The therapeutic effects of the Herbst appliance are slightly larger, although not significantly. CLINICAL RELEVANCE: Treatment with either Herbst appliance of FMA alters the hyoid bone position and enlarges the posterior airway space. Still, long-term data are as yet unavailable; it remains unknown if the effects upon posterior airway space remain stable, and if a resulting posterior airway space enlargement may have clinical influence upon obstructive sleep apnoea syndrome.


Asunto(s)
Maloclusión de Angle Clase II , Aparatos Ortodóncicos Funcionales , Cefalometría , Epiglotis , Humanos , Hueso Hioides , Maloclusión de Angle Clase II/terapia , Mandíbula , Aparatos Ortodóncicos Fijos , Estudios Retrospectivos , Férulas (Fijadores)
10.
Eur J Orthod ; 43(2): 152-158, 2021 04 03.
Artículo en Inglés | MEDLINE | ID: mdl-33351886

RESUMEN

BACKGROUND: Retention of the maxillary anterior teeth is commonly recommended to maintain the teeth in their corrected positions. Both fixed and removable retention methods are used, but the certainty of evidence is low. OBJECTIVE: To evaluate post-treatment changes in irregularity of the maxillary six anterior teeth and single tooth contact point discrepancy (CPD) of three different retention methods. TRIAL DESIGN: Three-arm parallel group single-centre randomized controlled trial. MATERIALS AND METHODS: Ninety patients, 54 girls and 36 boys, were recruited to the study. The inclusion criteria were adolescent patients treated with fixed appliances at least in the maxilla. After gaining informed consent from the patient and their custodians, the patients were randomized to one of three groups: bonded retainer 13-23, bonded retainer 12-22, and removable vacuum-formed retainer (VFR) covering the maxillary teeth including the second molars. The randomization, prepared by an independent person, used blocks of 30. The primary outcomes were changes in single CPD and Little's irregularity index (LII) measured on digitalized three-dimensional study casts before and after 2-year retention. The study casts were anonymized before assessment and the changes were blinded for the assessor. Data were evaluated on an intention-to-treat basis. Thus, all randomized patients were incorporated into the final analysis. RESULTS: The LII and CPDs increased slightly in all three groups without any statistically significant differences between the groups. The VFR group showed a small intercanine width increase and some more changes of canine rotations than in the other groups. HARMS: No harm was observed in any subjects and none of the patients needed retreatment. LIMITATIONS: The trial was a single-centre study and short-term changes were evaluated. CONCLUSIONS: All three retention methods showed equally effective retention capacity and all the changes found in the three groups were small and considered clinically insignificant. Thus, the null hypothesis was confirmed. All three methods can be recommended. TRIAL REGISTRATION: NCT04616755.


Asunto(s)
Retenedores Ortodóncicos , Ortodoncia Correctiva , Adolescente , Femenino , Humanos , Masculino , Diseño de Aparato Ortodóncico , Aparatos Ortodóncicos Fijos , Vacio
15.
Artículo en Inglés | MEDLINE | ID: mdl-33317118

RESUMEN

BACKGROUND: To evaluate the effectiveness of conservative treatment with functional appliances for condylar fractures in pediatric age. METHODS: Four electronic databases (PubMed, EBSCO, Scopus, and Web of Science) were consulted with no restriction of publication status or year, up to 31 August 2020. SELECTION CRITERIA: based on the PICOS criteria, the selection criteria were set for observational human studies, with at least 10 patients and six months of follow-up. The study population included pediatric patients (aged 5-16 years), with unilateral or bilateral condylar fracture, treated with functional appliances. Condylar remodeling and mandibular growth were analyzed through sequential radiographic examinations. DATA COLLECTION AND ANALYSIS: Two independent reviewers carried out title-abstract screening, and a senior investigator was involved to solve any disagreement. The quality of the evidence was assessed through the Canada Institute of Health Economics (IHE) quality appraisal checklist, and the National Institutes of Health (NIH) quality assessment tool. RESULTS: A total of 971 articles were retrieved from the electronic search; among them, three studies met the eligibility criteria. A moderate risk of bias was detected in all the studies, due to common limitations (absence of multicenter studies, prospective design, blindness of the investigators, patients' drop-out). At follow-up examinations (between 6 months and 4.9 years), the difference of condylar neck length between the "injured" and "healthy" side was approximately 2 mm, while the anteroposterior condylar width discrepancy was recorded up to 1 mm. CONCLUSIONS: Short- and long-term data revealed that conservative treatment with functional appliances led to partial or full radiological recovery of the joint morphology, along with good to excellent functional results. Patients' age has a crucial role on the treatment choice, and the type of fracture (presence of condylar displacement, or dislocation) is also a major prognostic indicator of the radiologic outcome. LIMITATION: To confirm the effectiveness of functional appliances, more prospective clinical long-term follow-up studies with homogeneous samples of condylar fractures are deemed necessary. Registration: The study protocol was registered on PROSPERO (CRD42020205650).


Asunto(s)
Tratamiento Conservador , Fracturas Mandibulares , Adolescente , Canadá , Niño , Preescolar , Tratamiento Conservador/estadística & datos numéricos , Humanos , Fracturas Mandibulares/diagnóstico por imagen , Fracturas Mandibulares/terapia , Aparatos Ortodóncicos Fijos/estadística & datos numéricos , Estudios Prospectivos , Radiografía Panorámica , Estudios Retrospectivos , Resultado del Tratamiento
16.
Evid Based Dent ; 21(4): 144-145, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33339979

RESUMEN

Design Systematic review for randomised and non-randomised studies.Data sources Eight electronic databases: PubMed, Cochrane, Scopus, Web of Science, Lilacs, Google Scholar, Clinical Trials and OpenGrey were searched without language or date restrictions during the search, in addition to hand-searching.Study selection Randomised and non-randomised controlled trials (RCTs and non-RCTs) and cross-sectional studies that compare pain levels between fixed appliances and clear aligners during orthodontic treatment in adults patients.Data extraction and synthesis The reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study selection was done by two reviewers. The reviewers assessed the risk of bias using three risk of bias tools (ROB.2 tool for RCTs, ROBINS-I tool for non-RCTs and the Newcastle-Ottawa scale for cross-sectional studies).Results Seven studies were included in this review. Five studies were non-RCTs, one was an RCT and one study was a cross-sectional design. The risk of bias was moderate to high in the non-RCTs, low in the RCT and low for the cross-sectional study. All studies used the same type of aligners (Invisalign aligner) and they differed in the fixed appliance type and archwire sequences. However, meta-analysis was not possible. In the first 24 hours of treatment, four studies revealed that the pain is higher in the fixed appliance group. During days three and four, two studies reported a higher level of pain in a fixed appliance group. On days five to seven, only one study reported a higher level of pain in a fixed appliance group. On day 14, two studies evaluated pain levels and reported that there is no difference between the two groups.Conclusions With low certainty, patients treated with clear aligners seems to have less pain perception than patients treated with conventional fixed appliances during the first days of treatment. There were no noticeable differences up to three months between the two groups. Furthermore, the malocclusion was not described in detail in the individual studies, which may play a role in pain level differences.


Asunto(s)
Maloclusión , Aparatos Ortodóncicos Removibles , Adulto , Estudios Transversales , Humanos , Aparatos Ortodóncicos Fijos , Dolor
17.
Evid Based Dent ; 21(4): 146-149, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33339980

RESUMEN

Data sources The following electronic databases were searched from 1946 to 31 August 2019: Medline, Embase, the Cochrane Oral Health Group's Trials Register, CENTRAL, ClinicalTrials.gov, the National Research Register and Pro-Quest Dissertation Abstracts and Thesis database.Study selection The following study designs were eligible: randomised controlled trials (RCTs), controlled clinical trials, cohort studies of prospective and retrospective design, and cross-sectional studies that reported periodontal measurements on patients who received fixed retention after orthodontic therapy. Studies irrespective of their language were selected by two reviewers independently.Data extraction and synthesis Data extraction from the selected studies and risk of bias assessments were performed by two reviewers independently. Specific risk of bias tools were used according to the pertinent research designs of the included studies. Criteria for conducting a meta-analysis were not met and a qualitative synthesis was conducted.Results Twenty-nine studies fulfilled the eligibility criteria; that is, 11 RCTs, four prospective cohort studies, one retrospective cohort study and 13 cross-sectional studies. The quality of the evidence was low for most of the studies included in this review. Contrary to the general consensus, two RCTs, one prospective cohort study and two cross-sectional studies identified poorer periodontal health in patients with fixed orthodontic retainers.Conclusions The authors of this systematic review concluded that fixed orthodontic retainers in the majority of the 29 included studies seemed to be a method of retention that is rather compatible with periodontal health, or at least not related to severe detrimental consequences for the periodontium. No recommendations on the best type of fixed retainer to use could be given. High-quality evidence from long-term studies is necessary to provide definitive conclusions on the relationship between fixed retainers and periodontal health.


Asunto(s)
Aparatos Ortodóncicos Fijos , Retenedores Ortodóncicos , Estudios Transversales , Humanos , Estudios Prospectivos , Estudios Retrospectivos
18.
Medicine (Baltimore) ; 99(50): e23165, 2020 Dec 11.
Artículo en Inglés | MEDLINE | ID: mdl-33327234

RESUMEN

BACKGROUND: Although several researchers have analyzed the dental identity of patients experience with corrective methods using fixed and removable appliances, the consequences stay debatable. This meta-analysis intended to verify whether the periodontal status of removable appliances is similar to that of the conventional fixed appliances. METHODS: Relevant literature was retrieved from the database of Cochrane library, PubMed, EMBASE, and CNKI until December 2019, without time or language restrictions. Comparative clinical studies assessing periodontal conditions between removable appliances and fixed appliances were included for analysis. The data was analyzed using the Stata 12.0 software. RESULTS: A total of 13 articles involving 598 subjects were selected for this meta-analysis. We found that the plaque index (PLI) identity of the removable appliances group was significantly lower compared to the fixed appliances group at 3 months (OR = -0.57, 95% CI: -0.98 to -0.16, P = .006) and 6 months (OR = -1.10, 95% CI: -1.60 to -0.61, P = .000). The gingival index (GI) of the removable appliances group was lower at 6 months (OR = -1.14, 95% CI: -1.95 to -0.34, P = .005), but the difference was not statistically significant at 3 months (OR = -0.20, 95% CI: -0.50 to 0.10, P = .185) when compared with that of the fixed appliances group. The sulcus probing depth (SPD) of the removable appliances group was lower compared to the fixed appliances group at 3 months (OR = -0.26, 95% CI: -0.52 to -0.01, P = .047) and 6 months (OR = -0.42, 95% CI: -0.83 to -0.01, P = .045). The shape of the funnel plot was symmetrical, indicating no obvious publication bias in the Begg test (P = .174); the Egger test also indicated no obvious publication bias (P = .1). CONCLUSION: Our meta-analysis demonstrated that malocclusion patients treated with the removable appliances demonstrated a better periodontal status as compared with those treated with fixed orthodontic appliances. However, the analyses of more numbers of clinical trials are warranted to confirm this conclusion.


Asunto(s)
Maloclusión/terapia , Aparatos Ortodóncicos Fijos/efectos adversos , Aparatos Ortodóncicos Removibles/efectos adversos , Enfermedades Periodontales/etiología , Adolescente , Adulto , Niño , Femenino , Humanos , Masculino , Maloclusión/clasificación , Maloclusión/diagnóstico , Persona de Mediana Edad , Diseño de Aparato Ortodóncico/tendencias , Aparatos Ortodóncicos/provisión & distribución , Evaluación de Resultado en la Atención de Salud , Enfermedades Periodontales/epidemiología , Índice Periodontal , Ensayos Clínicos Controlados Aleatorios como Asunto
19.
Angle Orthod ; 90(5): 634-639, 2020 09 01.
Artículo en Inglés | MEDLINE | ID: mdl-33378478

RESUMEN

OBJECTIVES: To examine the effect of micro-osteoperforation (MOP) on the space closure rate using passive self-ligating or conventional brackets. MATERIALS AND METHODS: This was a two-arm parallel randomized controlled trial undertaken at the outpatient department of a dental college. There were 60 participants (30 women and 30 men) who fulfilled the inclusion criteria. Both the study and control groups were subjected to MOPs throughout the period of space closure. MOPs were repeated every 28 days. The experimental group (mean age 19.5 ± 1.66 years) was bonded with passive self-ligating brackets while the control group (mean age 19.9 ± 1.13 years) was bonded with conventional brackets. Both groups were examined and compared for rate of space closure. An evaluation was conducted for both groups until the entire extraction space was closed and confirmed by evaluation of a tight contact between the canine and the second premolar using a piece of dental floss. RESULTS: Before the initiation of retraction, all initial criteria were similar between the two groups (P > .05). No difference was observed between the two groups in the rate of space closure (P > .05). CONCLUSIONS: MOP in conjunction with passive self-ligation does not increase the rate of orthodontic space closure when compared with MOP used with conventional brackets.


Asunto(s)
Soportes Ortodóncicos , Cierre del Espacio Ortodóncico , Adolescente , Adulto , Diente Premolar/cirugía , Femenino , Humanos , Masculino , Diseño de Aparato Ortodóncico , Aparatos Ortodóncicos Fijos , Alambres para Ortodoncia , Técnicas de Movimiento Dental , Adulto Joven
20.
Angle Orthod ; 90(4): 485-490, 2020 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-33378505

RESUMEN

OBJECTIVE: To assess the efficacy and efficiency of treatment in adolescents presenting with mild malocclusions, comparing outcomes using clear aligners to fixed appliances. MATERIALS AND METHODS: Patients identified retrospectively and consecutively from one private practice had been treated with either clear aligners (Invisalign, Align Technology, Santa Clara, Calif) or fixed appliances (0.022 Damon, Ormco, Orange, Calif; n = 26/group). Assessments of occlusion were made using the American Board of Orthodontics Discrepancy Index (DI) for initial records and Cast-Radiograph Evaluation (CRE) for final records. Number of appointments, number of emergency visits, and overall treatment time were determined from chart reviews. Data were analyzed using Pearson's correlation, Wilcoxon rank tests, unpaired t-tests, and Chi-square tests, with significance set to P ≤ .05. RESULTS: Pretreatment, the aligner and fixed groups showed no significant difference in overall severity (DI: 11.9 ± 5.3 vs 11.6 ± 4.8) or in any individual DI category. Posttreatment scores showed finishes for the aligner group had fewer discrepancies from ideal relative to the fixed appliance group (CRE: 30.1 ± 8.3 vs 37.0 ± 9.3; P < .01). Patients treated with aligners had fewer appointments (13.7 ± 4.4 vs 19.3 ± 3.6; P < .0001), fewer emergency visits (0.8 ± 1.0 vs 3.6 ± 2.5; P < .0001), and shorter overall treatment time (16.9 ± 5.7 vs 23.4 ± 4.4 months; P < .0001). CONCLUSIONS: Outcomes for treatment of mild malocclusions in adolescents showed equivalent effectiveness of clear aligners compared to fixed appliances, with significantly improved results for clear aligner treatment in terms of tooth alignment, occlusal relations, and overjet. Assessment of the number of appointments, number of emergency visits, and overall treatment time showed better outcomes for treatment with clear aligners.


Asunto(s)
Maloclusión , Aparatos Ortodóncicos Removibles , Adolescente , Humanos , Maloclusión/terapia , Diseño de Aparato Ortodóncico , Aparatos Ortodóncicos Fijos , Evaluación de Resultado en la Atención de Salud , Estudios Retrospectivos , Resultado del Tratamiento
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