Fixed Orthodontic Appliance (Dentistry) #Braces
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Transcript of Fixed Orthodontic Appliance (Dentistry) #Braces
#ORTHODONTICFixed AppliancesDR. SARANG SURESH HOTCHANDANI| CHAPTER 10
05/02/2023DR. SARANG - S - HOTCHANDANI
2Contents
Introduction to Fixed Appliances Indications & Contraindications of Fixed Appliances Difference b/w Fixed & Removable Appliances Types of Fixed Appliances Orthodontic Bends in Fixed Appliances Components along with Placement Removal of Fixed Appliances Prevention & Treatment of White Spots after Orthodontic Tx. Problems with Fixed Appliances Temporary Anchorage Devices
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3Orthodontic Appliances
Fixed Orthodontic Appliances Functional Orthodontic ApplianceRemovable Orthodontic Appliances
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4Introduction to Fixed Appliances
These are orthodontic devices, which have attachments that are fixed onto the tooth surface, and force are exerted on tooth via these attachments using arch wires and other auxiliaries.
These appliances cannot be removed or activated by patient.
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5Indications of Fixed Appliances
Correction of mild to moderate skeletal discrepancy.
Intrusion/Extrusion of teeth.
Corrections of rotation.
Overbite reduction by intrusion of incisors.
Multiple tooth movements required in one arch.
Active closure of extraction space, or space due to Hypodontia.
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6Contraindications of Fixed Appliances
Poorly motivated patient
Poor dental health
Extremely sever malocclusion requiring orthognathic surgery
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7Fixed V/S Removable Appliances
FIXED APPLIANCE REMOVABLE APPLIANCEPrecise 3 dimensional tooth movement Less precise control of tooth movementBodily tooth movement Tipping tooth movement onlyComplex malocclusions can be treated Simple malocclusions onlyHigh anchorage requirements Small anchorage requirementsControlled space closure possible Space closure is difficultMultiple tooth movements Few tooth movementsCan be used in upper or lower arch Retention in lower arch is poorSimple to correct rotations More difficult to correct rotationsOral hygiene can be problematic Can be removed for oral hygieneNot dependent on patient’s compliance
Depend on patient’s compliance
Long chairside time Short chair side timeRequire extensive training Require less training to manage.
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8Fixed Appliances
Contemporary fixed appliances are variations of Edge wise appliance system.
Another system of fixed appliance is Begg appliance system. It contains rectangular slot but does not use rectangular arch wire.
Currently Begg appliance system has been modified into Tip – Edge appliance system.
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9
Fixed Appliances
Edgewise
Standard Edgewise
Contemporary /Straight Edgewise
Begg Appliance
Tip Edge Appliance
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10Ribbon Arch
It was made by Edward Angle.
It contains vertically positioned rectangular slots in which arch wire of 10x20 gold wire was placed into the vertical slots and held with pins.
It had poor control of root position and does not generated torque.
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11Edgewise
angle modified that ribbon arch appliance, in which he Reoriented the slot from vertical to horizontal and inserted a rectangular wire rotated 90 degrees to the orientation it had with ribbon arch, thus the name edge wise.
The dimension in that slot were 22 x 28 mils & wire of 22 x 28 mil precious metal was used.
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12Begg Appliance
It is a modification of ribbon arch appliance, in which Raymond Begg modified following things in the appliance. He replaced the precious metal ribbon arch with 16 mils round stainless steel wire
He retained original ribbon arch bracket, but turned it upside down so that the bracket pointed gingival rather occlusally.
He added auxiliary springs to the appliance for control of root position & cause rotation in tooth.
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13Advantages & Limitations of Begg Appliance
Advantage of Begg Appliance Tipping movement Bite opening Friction was minimized Binding was minimized (mentioned in chapter 9)
Limitations of Begg Appliance Finishing Cumbersome Technique
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14Tip Edgewise Appliance
It is a hybrid appliance having combination of Begg & Edge wise mechanics (straight wire mechanics of edge wise)
It allows tipping of tooth in the initial stages of treatment with round wires – Begg technique. In latter stages, rectangular wires are used for final tooth
positioning.
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15
Contemporary Edgewise Appliances
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16Modern edgewise appliances are of two types;
Standard/Original Edge wise appliance system
Straight wire/ Contemporary edgewise appliance system
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17STANDARD EDGEWISE APPLIANCE SYSTEM
Rotation of tooth was controlled by separate ligatures tied to the eyelets soldered to the corners of bands
Bracket slot size was 22 x 18
Same bracket on all teeth That’s why bends were given to
compensate for difference in tooth anatomy.
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18Bends in Standard Edgewise
1st Order Bends/ In – Out Bend/ Facio – Lingual Bends
2nd Order Bends/ Tip Bends/ Artistic Bends
3rd Order Bends/ Torque Bends
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191st order Bend OR in – out bend ORfacio – lingual bends
This bend was given to compensate for variation in the contour of labial surface of individual teeth (differing tooth width & buccolingual direction of teeth).
These bends are given in horizontal or in the plane of arch wire.
Can be given in rectangular or round wire
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202nd order bend/ tip bends/ artistic positioning bends
These bends were given to achieve proper mesiodistal root position or tilting of teeth.
They are given in vertical plane
Can be given in rectangular or round wire.
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213rd order bends/ torque bends
These bends are given only in rectangular wire.
These bends are made by twisting the wire and is inserted into bracket slot so that is can exert Bucco lingual force on the root apex.
These bends were given for moving the roots facially or lingually and also to avoid movement of properly positioned teeth.
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22
Orthodontic Bends
a) 1st order bend
b) 2nd order bend
c) 3rd order bend
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23
Straight wire Edge Appliance
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24Straight wire edgewise appliance
They are modern edgewise appliances
In these appliance rotation is not controlled by separate ligature but it is built in the bracket itself.
Bracket slot size is available in two forms; 18 x 28 mills & 22 x 28 mill slot size.
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25Straight wire edgewise appliance
Different brackets for different teeth. This thing eliminated the bends which were given in standard edgewise.
In these appliances no any 1st order bend is given, instead, compensation for the contour of labial surface of teeth is built into the base of bracket.
In straight arch wire appliances, positioning of root is accomplished by proper angulation of bracket or bracket slot. This thing decreased the need for 2nd order bends.
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26Straight wire edgewise appliance
The bracket slots in the straight wire edgewise appliances are inclined to compensate for proper inclination of facial surface, so that’s why 3rd order bends are not given.
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27
Straight wire edgewise appliance
Diagram (a) shows an edgewise bracket with a 2nd order bend placed in the arch wire to achieve the desired movement of tip.
Diagram (b) shows a pre – adjusted bracket with tip built into the bracket slot.
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28Components of Fixed Appliances
Bands Bonds/ BracketsOrthodontic Adhesive
Auxiliaries
Arch wires
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29
Orthodontic Bands
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30Orthodontic Bands
These are the rings which encircle the tooth & to which buccal and/or lingual attachments are soldered or welded.
Before acid etching technique, brackets were attached on bands which are then cemented on tooth.
They are not used now days except only on molar teeth.
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31Indications Where Brackets Are Still Applied On Bands
Teeth that will receive heavy intermittent force; maxillary 1st molar in which force is
applied via headgear
Teeth that will need both labial and lingual attachments Molar with both headgear and lingual
arch tube. Isolated lingual bracket.
Teeth with short clinical crowns
Teeth with extensive restoration Bond strength is low on restorations.
De bonding from porcelain damages its appearance.
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32
Rules of Banding & Bonding in Contemporary Orthodontics
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33Steps in Placement of Orthodontic Bands
Separation
Fitting
Cementation
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34Separation
Teeth must be separated before banding, because tight inter proximal contacts make it impossible to properly seat a band.
Principle of Separation; a device to force or wedge the teeth apart is left in place long enough for initial tooth movement to occur, so that the teeth are slightly separated by the appointment at which bands are to be fitted.
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35Methods of Separation
Separating Springs
Elastomeric Separators / doughnuts
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36Separating Springs
They exert scissor action above and below the contact.
Open the contact points within 1 week. Should not be placed more than 1 week.
Easier to tolerate.
Disadvantages; these separators tend to become loose & fall out as they accomplish their purpose.
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37Method of Separation with Steel Separating Spring
A. The spring is grasped at the base.
B. The bent – over end of the longer leg is placed in lingual embrasure, and the spring is pulled open so the shorter leg can slip beneath the contact.
C. The spring in place, with the helix to the buccal.
D. The spring can be removed most easily by squeezing the helix, forcing the legs apart.
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38Method of Separation with Steel Separating Spring
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39ELASTOMERIC SEPARATORS (DOUGHNUTS)
They surround the contact point & squeeze the teeth apart.
More difficult to insert but they are retained for long time without fall.
Always use bright colored elastomeric separators because they are radiolucent.
They should be placed not more than 2 weeks.
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40Method of Separation with Elastomeric Ring
The elastomeric ring is placed over the beaks of a special pliers and stretched, then
one side is snapped through the contact and the pliers slipped out so that the doughnut now surrounds the contact; C,
an alternative to the special pliers is two loops of dental floss, placed so they can be used to stretch the ring.
The dental floss is snapped through the contact and the doughnut is pulled underneath the contact;
the doughnut is pulled upward, and the doughnut is snapped into position. At that point, the dental floss is removed.
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41Method of Separation with Elastomeric Ring
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42Fitting the Bands
Maxillary molar band placement placed initially by hand pressure on the
mesial & distal surfaces. After placement
pressure is applied on mesiobuccal and distolingual surfaces.
Final seating is with heavy biting force by patient on the distolingual corner.
Mandibular molar band placement Seated initially with hand
pressure on proximal surfaces and then with
Heavy biting force along the buccal but not lingual margins.
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43Cementation of Molar Bands
All interior surfaces of orthodontic band must be coated with cement before it is placed.
Place a gloved finger over the top of the band when it is carried to place, to help in keeping cement on the gingival aspect of band.
Cement Materials; Zinc phosphate GIC Resin modified GIC
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44
Orthodontic Brackets
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45Brackets
They are appliances that are fixed to crown & mediate forces applied by the arch wire & auxiliaries on tooth.
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46Types of Brackets
MATERIALS Cast or metal injected molded
stainless steel brackets
Titanium brackets
Cobalt chromium brackets
Ceramic brackets
DESIGN Edgewise bracket/ straight wire
Light wire appliance brackets/ tip edge bracket
Self-ligating brackets
Lingual brackets
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47Components of Brackets
• 18 x 18 or 22 X 18
Wings Slots
BaseMesh
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48Bonding of Bracket
Bonding is based on the mechanical locking of an adhesive to irregularities in the enamel surface of the tooth and to mechanical locks formed in the base of bracket.
Brackets are mechanically bonded to tooth surface. Chemical bonded is avoided because it will create problems in debonding of bracket
Bonding Materials in Orthodontics Light cured bis – GMA resin Self-cured or light cured
composites GIC
Less decalcification because of fluoride release
Less strength & greater chance of loos brackets
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49Types of Bonding Bracket
DIRECT BONDING places the brackets on the teeth
individually at the chairside; and
Advantages; easier, faster, less expensive
Disadvantage; no proper position of bracket
INDIRECT BONDING places the brackets on study models in the
laboratory and these are transferred to the teeth using a positioning tray. it is used when placing lingual fixed appliances.
Advantages greater accuracy of bracket positioning
Disadvantage extra cost and time
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50Cleaning the tooth surface, to remove any pellicle using a slow hand piece and prophy brush
or cup;
Acid-etching the enamel surface
using 37% unbuffered
phosphoric acid for 20 – 30 seconds;
Washing and drying the tooth
surface
Placing unfilled primer on the
etched area of the tooth;
Placing composite resin on the bracket base
Positioning the bracket on the
tooth crown
Cleaning up excess composite from around the
bracket base
Curing the composite, either chemically or with a blue light source
Steps in Direct Bonding of Bracket
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52
INDIRECT BONDING
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53
The teeth are isolated, etched, and a chemically cured two-paste resin is painted on the etched enamel and the brackets. Then, the transfer trays are inserted. D, After the resin has completely set, the trays are carefully removed, leaving the brackets bonded to the
teeth.
After the brackets are cured in the ideal position, a transfer tray is formed from a vinyl polysiloxane puttyThe trays are removed from the working cast after soaking in warm water
and trimmed
Brackets are placed precisely as desired on a cast of the teeth and held in place with a filled resin.
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54
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55
De Banding & De Bonding
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56Removal of Molar Band
Distort the band with force which will break the cement away from band & tooth and remove it.
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57Removal of Bracket
When bracket is one of the following things happen; Breakage b/w cement & bracket (preferred) Breakage within the cement material itself Breakage b/w enamel surface & cement (least desired)
The safest way to remove metal bracket is to distort the bracket base, which cause breakage b/w bracket & cement. This damages the bracket and it cannot be reused.
Ceramic brackets on removal damages the enamel because they break before bend.
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58
Prevention & Treatment of Enamel Decalcification/White Spots after Orthodontic Tx.
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59Prevention
Fluoridated water & fluoride containing toothpaste
0.05% neutral sodium fluoride rinse
Caries Prone patient; fluoride varnish application at 6-month interval
Chlorhexidine mouthwash for 14 days.
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60Remineralizati
on Therapy
External Bleaching
Micro Abrasion
Veneers
Treatment of White Spots after Ortho Tx.
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61Characteristics of Contemporary Brackets – CERAMIC BRACKETS
Durable, resist staining, dimensionally stable
Types of ceramic bracket based on the material; Polycrystalline alumina Polycrystalline alumina with metal slot Monocrystalline alumina
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62Problems with Ceramic Brackets
Fracture of bracket
Friction within bracket slot
Attrition on teeth contacting the bracket That’s why mostly placed on upper
teeth only.
Enamel damage on bracket removal
Chemical bonding which is strong, mechanical bonding difficult in ceramic bracket.
Brittle, that’s why they are made bulky and act as wide bracket. (effects of wide bracket learnt in 9th chapter)
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63
Straight Wire Concept in Bracket
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64Straight Wire Concept in Bracket
Compensation for 1st order bends; For anterior teeth and
premolars, changing the bracket thickness eliminate in – out bends in anterior portion of arch wire. But molar tube on molar bend should be offset position to prevent molar rotation.
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65Straight Wire Concept in Bracket
Because for good occlusion, the buccal surface of molar must sit at an angle to line of occlusion. Mesio buccal cusp more prominent
That’s why the tube on the molar band should be at least 10 degree offset for maxillary molar. On mandibular molar it should be 5 – 7 degrees.
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66Straight Wire Concept in Bracket
A distal inclination or tip of the maxillary first molar is important for proper posterior occlusal interdigitating. If the mesiobuccal cusp occludes in the mesial groove of the mandibular first molar, creating an apparently ideal Class I relationship, proper interdigitating of the premolars still cannot be obtained if the molar is positioned too upright
Tipping the molar distally allows the premolars to interdigitate properly
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67Self Ligating Brackets
In this ligatures are not needed for holding wire, but the mechanism for retention of wire is built within the brackets.
Types of self – ligating brackets; Springy latching cap
Smart clip system Springy retaining clips
Innovation system Speed system
Rigid latching caps Damon system
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68
Archwires
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69Orthodontic Archwires
During initial alignment phase; NiTi wire Stainless steel wire Coaxial wire
To complete the process of levelling, beginning of overbite reduction, sliding of teeth along arch wire; Round Stainless steel wire
Arch wires during the later stages of overbite reduction and for space closure; Rectangular stainless steel wire
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70Orthodontic Archwires
NiTi wire is ideal for aligning teeth during initial stages of Tx. However, for later stages, space closure & overbite reduction, NiTi
cannot be used.
In the initial stages of treatment, a wire which is flexible with good resistance to permanent deformation is desirable, so that displaced teeth can be aligned without the application of excessive forces.
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71Orthodontic Archwires
Initial Alignment (minimum stiffness, maximum range) Ni-Ti wire Multi-stranded wires
Mid Treatment (Series of working wires with increasing stiffness and reduced range)
Finishing & Detailing (Maximum Stiffness, snuggly fit rectangular wire)
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72
Auxiliaries
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73Auxiliaries
They are used to apply active forces for space opening or closure.
Elastic materials can be used for intra-arch (intra-maxillary) space closure, and springs constructed from stainless steel or nickel titanium can be used for space opening.
Types of Auxiliaries;Elastic bandsWire ligaturesIntra oral elasticsPalatal or lingual archesCoiled springsPower chains
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74Problems with Fixed Appliances
Pain
Tooth mobility
Mucosal trauma Orthodontic wax can be used to cushion the wire
Bracket failure
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Temporary Anchorage Devices
• BONE SCREWS• MINIPLATES
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76Indications of bone screws
Positioning of individual teeth: Missing teeth – lack of anchorage Impacted teeth
Position of groups of teeth; Space closure
Major incisor retraction Incisor retraction & intrusion
Mesial movement Maxillary & mandibular posterior teeth Entire mandibular arch
Intrusion of anterior or posterior but not both simultaneously
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77Indications of miniplates
Positioning groups of teeth. Distalization of entire maxillary & mandibular arch. Intrusion of anterior & posterior teeth
Growth modification. Class III elastics, maxillary deficient child. Restriction of vertical maxillary growth.
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78References
Cobourne, M. T. (2010). Handbook of Orthodontics. Mosby Elsevier.
Gill, D. (n.d.). Orthodontics at a Glance 1st Edition. Blackwell.
Mitchell, L. (n.d.). Introduction to Orthodontics 4th Edition. Oxford.
Proffit, W. R. (n.d.). Contemporary Orthodontics 5th Edition. Elsevier.
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THE ENDDR. SARANG SURESH
HOTCHANDANIBDSBibi Aseefa Dental College, SMBBMU.Larkana, Sindh, Pakistan
Email: [email protected]: http://www.slideshare.net/sarangsureshhotchandaniTwitter: https://twitter.com/fetusdentista