The advantages of fixed orthodontic treatment

ABSTRACT

Background

Treatment with fixed orthodontic appliances resulting in differences in jaw rotation is a factor that affects the occlusal bite force, and the occlusal bite force before and after various orthodontic and surgical procedures has been reported to be different^. The maximum occlusal bite force is a useful indicator that detects the functionality of the masticatory coordination, and we gain essential information to assess the stability and activity of the jaw muscles by measuring the bite force. Orthodontic treatment leads to a change in the patients’ occlusion condition as improvement in the state of malocclusion occurs. Many factors are responsible for the variation of the occlusal bite force between the people.

Therefore it is important for an orthodontist to have a thorough knowledge of the patient’s masticatory function, and as stated, occlusal bite force is a key factor in determining the normal jaw function and activity; its measurement will be an aid during orthodontic treatment.

Objective

The objective of this study will be:

1. To compare changes in occlusal bite force during orthodontic treatment at different intervals compared to those not undergoing fixed orthodontic treatment.
2. To compare changes in occlusal bite force between subjects treated by extraction and those by non-extraction.

Methods

A Quasi-experimental study was conducted at, Orthodontic department. The study includes 90 patients aged 15-30 years selected on the basis of the following criteria: no previous orthodontic treatment, and no congenitally absent or missing permanent teeth. The subjects were divided into a control group and a treatment group. The collected data were statistically analyzed using the Statistical Package for Social Sciences (SPSS) Version 22 software. Repeated measures analysis of variance (ANOVA) tests were applied to check the mean difference in OBF at different intervals, and the mean difference between extraction and non-extraction subjects will be assessed by independent t-test.

Result

The independent t-test displayed that there was no significant difference between the two groups, extracted and non-extracted, except at the time of the final reading on the 9^th month of treatment. Therefore, this indicates although there was no significant difference between the occlusal bite forces of extracted or none extracted cases before and during the treatment; however, the end result of the treatment provides a significant difference in the bite force presenting with better results of treatment in non extracted cases.

In addition, the means of each group were compared through the rANOVA test to assess any significant difference. The results clearly displayed a significant difference in the treatment group with the p-value equal to 0.01, which is <0.05. Hence the alternative hypothesis remains authentic while the null hypothesis is rejected.

Conclusion

The placement of the fix appliance causes a change in the occlusal bite force, and gradually with the alignment of the teeth, the occlusal force increases as the teeth are now in a more functional position.

Key Words

Occlusal bite force, Occlusal bite force gauge, Masticatory function

ABBREVIATIONS:

Occlusal Bite Force (OBF)

Bite Force Gauge (BFG)

Repeated measures analysis of variance (rANOVA)

Maximum Voluntary Bite Force (MVBF)

INTRODUCTION

Orthodontics is said to be that branch of dentistry which takes into consideration the facial growth, dentition development as well as occlusion. It is also concerned with the prevention as well as the rectification of the occlusal anomalies.¹ The primary aim of the orthodontic treatment is to ensure that the three main areas, like that of oral functions, aesthetics, as well as the general dental health of a person, can be improved. It can be therefore said that orthodontics help in the elimination of all the functional problems which could incline a patient towards the various aspects like TMD.  It also facilitates the eruption as well as alignment of the teeth that are displaced or in some cases impacted, removal of any problems from displaced teeth and occlusion, improvement of the dental and facial features by means of aligning and leveling the teeth, correction of both the overjet and overbite so that a protective occlusion can be impacted and that all of this can take place in a soft tissue environment in a state of equilibrium.¹

The advantages of fixed orthodontic treatment include the reduction of the negative effect that the malocclusion has on both the dental as well as the psychosocial health of an individual.¹ However, this treatment is not at all risk-free and may include aspects like decalcification, root resorption, gingival and periodontal problems sometimes there can also be a failure in achieving the ultimate goal of the treatment. Therefore, it is extremely important that treatment is not commenced until and unless there is a fair chance of the patient benefitting from it.^1,2

Out of the various indicators used to evaluate the overall functions of occlusion, Occlusal Bite Force (OBF) is said to be one of the biggest and the most important indicator out of them to help predict the masticatory performance.² The two factors, which are the number, as well as the size of the occlusal contacts, are said to be the primary factors that determine the masticatory function, which is seen in individuals with complete dentition.³ The overall nature of these occlusal contacts determines at least 10 to 20% of the variations in terms of the maximum bite forces of the different adults.⁴

The Bite Force is that aspect that provides an indication about the state of the masticatory system, which is a product of the actions of the muscles of mastication, which are further improved by the craniomandibular biomechanics.⁴ The evaluation of the bite force of each individual is something that is used widely in Dentistry. This is done so that the mechanics of mastication can be understood in order to be able to assess the therapeutic effects of the different prosthetics devices and also so that proper reference values can be provided to studies that are undertaken on the mechanics of appliances.⁵ This method to check bite force is also done to diagnose the disturbances in the stomatognathic system.⁶ The bite force measure in an individual can be made by making use of an appropriate transducer that is placed between two teeth. This is said to be a direct method that is considered to the most convenient in case of assessing the overall submaximal force. Another option to this indirect method is that of an indirect evaluation which is undertaken in terms of the bite force. In this case, it is evaluated by taking into consideration the different physiologic variables which are known to be related in a functional manner to the force production in the mouth.⁷ The Electromyographic activity which takes place on the muscles of mastication can be understood by the proprioception on the muscular vectors.⁸

It is by using all of these ways that the data about the bite force can be obtained. There were also a number of investigations that showed a connection between the electric activity and measurement of the direct bite force, which is said to be at a submaximal level.⁷

There are a number of different factors that have an influence upon the maximal occlusal bite force. Therefore, various studies have been able to find out a different variety of highest bite force values. This huge variation of the bite forces is contingent on a number of different aspects that relate to the anatomical and physiologic features of the subjects. In addition to all of these factors, accuracy, as well as the accuracy of the bite force, is often influenced by the method by which bite force is recorded. ⁹

A reduction in the maximum bite force is said to be associated with a malocclusion.^10-12 Children that have a unilateral posterior crossbite showed a reduced occlusal bite force. They also have a lesser amount of occlusal contacts as parallel to the children who have normal occlusions.¹² There was a cross-sectional study that agreed to the fact that bite force could reduce right after commencing the unilateral crossbite treatment, however they also increased after retention because of which the bite force levels could reach to that of the children with a normal occlusion. It was then anticipated that the fluctuation which took place in the bite force during cross bite correction was because of the changes that took place in the occlusal contact as well as support.¹³

Also, a prospective study about the same topic helped in examining the changes about the average occlusal bite force of patients with the anterior crossbite in the primary detention and they were able to observe that the bite force was at its lowest when the crossbite was treated and it increased thereafter.¹⁴ A cross sectional study stated that the OBF increased after the orthodontic treatment than when it was before the appliance removal and it was found that females who had normal occlusions had improved masticatory functioning than their Class II equivalents.¹⁵

The maximum occlusal bite force is said to decrease at the time of orthodontic treatment. In a retrospective study, it was found that the OBF decreased in the subjects who were set to undergo orthognathic surgery.¹⁶ However, it was seen that unlike the other normal orthodontic treatments, the presurgical treatments were known to increase the overall severity of the malocclusion because of the decompensation process and also because the number of occlusal contacts get reduced during this time. Pain is also considered to be an important factor contributing to the limiting of the occlusal bite force because of the reflex mechanisms.^15,16,17 In a prospective study, it was reported that pain had a direct impact on the muscular action even though it did not originate from that point. The pain and discomfort caused by the fixed appliances as well as the decompensated occlusion created a reduction in the occlusal bite force both pre and postsurgical orthodontics.^16-19

The occlusal bite force gets affected by various physiological as well as morphological factors which include aspects like, age, gender, craniofacial morphology, height and body weight, temporomandibular disorders (TMD), periodontal support, pain, and dental status. ^20-32

Through various studies conclusion has been reached that individuals with long face require greater force at the time of mastication in comparison to the mesencephalic and brachyfacial patterns.³³ This can lead to overburdening of the weaker masticatory muscles and can then result into muscular pain as well as a lot of discomfort in the individuals that are known to have a long face.³⁴

It was also found that those individuals with restorative treatment had a lower bite force compared to their counterparts without restorative treatment such as fillings.³⁵ In addition; discomfort in these situations is considered to be a modifying aspect because of which biting force gets limited which is also a result of the different reflex mechanisms. There are a number of different effects that pain has on muscle activity; it happens at the time when the pain is not associated with that of the connecting muscle or joint.³⁵ Pain and discomfort are two factors which have the ability to reduce the OBF during any dental procedure be it restorative or orthodontic.^15-20,35

The maximum voluntary bite force has a direct relation with the masticatory system^35,36 and it has a great impact upon the muscle efficiency as well as development of the masticatory system in case of the dental development.^21,24,37 Therefore, it could also be used a method of the assessment of the same. The large variations which take place in the human bite force are the ones which are first recorded in the molar area. This can be ascertained from the number of studies which have been undertaken on a number of different people and by making use of a various  instruments as well as techniques.^5,7,38,39

There are a number of different factors that have an influence on MVFB which include factors like the state and stage of the dentition, the jaw closing muscle potency as well as the threshold of the pain of the subject. The bite forces are different in various regions of the oral cavity however the maximum is recorded in the molar area. The maximum force bite is therefore influenced by the degree of jaw opening as well as the overall muscle length.^11,40

This MVBF is also said to vary according to age. It is said to be higher in individuals who have a rectangular craniofacial morphology and deep bite and is lesser in the adults who have a long face and an open bite.^18,33 These correlations are however not seen that frequently in children. In some cases indicators of TMD happen to interfere with ideal mastication as well as the muscle potency in both younger as well as the elder subjects.⁴¹

The masticatory functioning is poorer in those patients who have a malocclusion than in those who have a normal occlusion.^11,41 In terms of the natural muscle strength, it is both strong and large in both males and females until the time they hit puberty. It is seen that the changes in bite forces which are gender related occur at the post pubertal period and there happens to be a superior muscle maturity which is influenced by hormones especially in males.²⁵ Also, a reduction in the occlusal force with the masticatory performance is usually associated with increased age. There have been some studies which have associated MVBF with age and gender and on the other hand there are some studies which state that it is influenced by BMI. However, there has been no study which has been able to predict the MVBF on these grounds.^18,25,41

Both malocclusions as well as compromised dentitions are linked with a reduced bite force. There are only aninadequate numbers of studies that talk about subjects which have a proper occlusion so that the MVBF can be defined in subjects that have malocclusion. Objective evidence for average values of MVFB in case of human detention would prove to be beneficial for both the researchers as well as specialists. The average values found in different age groups as well as the MVFB could be used as a base value for evaluation of the changes that occur in the orthodontic patient pre or post treatment. For the patients that have crowding or lips that are protruding their treatment plan would have to include an extraction protocol.⁴²  The decision of the extraction and the tooth which needs to be extracted would depend on the condition of the different patients and the first preference usually remains the premolars. In some cases, the process of extraction is often unavoidable and therefore both this process and the number of teeth that are extracted would have a huge impact upon the overall duration as well as the impact of both the treatment as well as outcome which may also include the final aesthetics as well as occlusion.⁴²

Orthodontics plays a massive part in improving the overall masticatory efficiency by aligning the dentition. The recovery of such functions can be understood by evaluating the different factors which have an effect on the occlusal contact which may include factors like occlusal contact points.^2,4 The occlusal function in the patients treated by the extraction protocol can be examined by dental casts. However, it is said that this method in association with the assessment rating index as well as the American Board of Orthodontics objective grading system provides a result which is only useful for static evaluation. There is a study which states that there are discrepancies between the results which have been obtained from the dental casts and the ones with the actual occlusal contact at the time of functional occlusion. The dental prescale system is one system which has been used widely in order to evaluate the occlusal contact area as well as force because of the fact that it is simple as well as objective. However, the problem is that the scope of the research by making use of this system is limited to the post-treatment changes that occur at the time of short follow up which spans over one year without taking into consideration the pre-treatment records. These kinds of studies include the patients who are treated with extractions.⁴²

Comprehensive review of the literature suggests that there are inadequate studies on changes in OBF during orthodontic treatment and further data is required to assess whether orthodontic treatment is a contributing factor to changes in forces of mastication. As the state of malocclusion improves so should the bite force. In previous studies OBF has been shown to increase in the first 6 months of orthodontic treatment, hence our study will help verify this linear increase with an additional measurement made at 9 months.⁹⁷ Over the years extracting teeth during orthodontic treatment has become a mainstay of treatment providing better stability. Our study will also help determine whether occlusal bite forces improve in those treated by extraction protocol and those by non extraction protocol.

LITERATURE REVIEW

The postnatal of facial as well as the dental structures have a life span of 18-25 years until an entire complement of 32 teeth takes its place. It is seen that a great amount of individual variation occurs at the time of skeletal as well as dental development in any given population.^1,21 It is because of these long formative periods that a lot of environmental as well as genetic influences have an effect upon the dentition as well as the facial morphologies. A lot of misunderstandings in terms of both preventive orthodontics as well as interceptive orthodontics occur due to the idea that an early treatment in the malocclusion of the children would reduce the need for any orthodontic treatment in the future. The problem with this idea is that the facial as well as dental development continues for the entire childhood as well as the adolescence of an individual because of which an impact of any long term treatment would not be predicted well.^14,23,43,44

However, the fact that an early treatment would help in the development of normal occlusion as well as facial harmony can in no way be denied.^14,45 The most common principles in case of early intervention includes the elimination of the primary etiologic factors if any, elimination of any occlusal discrepancies like that of unilateral, bilateral posterior crossbites, anterior crossbites as well as the correction of the skeletal dysplasia.^{14,23,37,45-48}

Another reason as to why an early orthodontic treatment is required is because they help in managing the arc length discrepancies so that any future extractions can be avoided in order to resolve the problem of crowding. It is said that any spontaneous relief of a pronounced mandibular anterior crowding becomes quite unlikely once the permanent lateral incisors emerge.^49,50 It was because of this fact that a number of serial extractions could be justified in the past cases. It is also said that the increasing mandibular intercanine distance which is fixed by orthodontic appliance therapy is not predicted to be as stable.^50,51

ORTHODONTICS

Orthodontics is that branch of dentistry which takes into consideration the facial growth, detention development as well as occlusion. It also helps in the prevention as well as correction of the occlusal anomalies.¹ The main reasons as to why an orthodontic treatment is undertaken is to improve the oral function, aesthetics as well as the dental health of an individual. The goal of the orthodontic treatment is to completely eliminate any functional problems which might make a patient vulnerable to TMD.^1,4 It also helps in encouraging the eruption as well as the overall alignment of any teeth which is displaced or impacted. It also helps in overcoming any trauma which occurs due to occlusion, displaced teeth.^43-46 It also helps in aligning as well as leveling the overall teeth by correcting the overjet as well as overbite so that a mutually protective occlusion can be formed in an environment which is stable for the soft tissues.¹

The main benefits of orthodontic treatment include the reduction of the negative impact of malocclusion which is upon the dental health as well as psycho social health of a human being.^43-46 Despite this fact, there are a number of different risks which are included in this process and may include aspects like decalcification, root resorption, gingival and periodontal problems etc. Hence, it is very important to ensure that no treatment is started before ascertaining whether or not there is a proper chance of the patient benefitting from it. Mostly, the orthodontic treatment depends on the stage of the dental development.¹ When a treatment takes place in a mixed dentition then it includes the extraction of the teeth that are deciduous and also leads to the correction of anterior as well as the posterior crossbite. Most of orthodontic treatment takes place at an early stage of the permanent detention. ^{1, 12, 13,14,23}

Treatment that is related to crowding or spacing is not shown in the primary detention, however, the crossbites which cause a displacement at the time of closing in either posterior or anterior is the one which can be treated successfully at this particular stage.^1,13,14 The maximum number of orthodontic treatments except that of growth modification can be done at the time of adulthood. Orthognathic surgery is the one which is usually delayed until this stage so that it can be assured that the growth has already been stopped.^1,16,17

TYPES OF ORTHODONTIC TREATMENT

In case there is an absence of any skeletal discrepancy there is a possibility of aligning the mal-aligned teeth when a sufficient amount of space is created by making use of fixed orthodontic appliances. There are various ways in which this space can be created and includes methods like the extraction of the specific teeth, expansion of the arch or the reduction of the interproximal enamel. If a patient is said to have a skeletal discrepancy then three ways of the orthodontic treatment can be used.

A) GROWTH MODIFICATION

Growth is a factor which is used to make corrections in the skeletal discrepancy. In order to fix a skeletal discrepancy by making use of the growth modification it is important that the patient keeps growing. This is the reason as to why this treatment is undertaken in the stage of late mixed or early permanent detention. This growth modification system is the one which makes use of a functional appliance as well as a headgear.^{1,11,13,14,25,43,45,49,52}

A significant level of arch length stability, establishment of a substantially large dental arch perimeter mesial to the permanent first molars were some aspects that were shown in a study and were the ones that also showed a significant amount of in the mandibular arch form as well as decrowding by making use of the vestibular shields in case of the functional appliances.^47,50,51 The lip bumpers which were less obtrusive became popular again because they were able to develop intercanine as well as the premolar width which eventually provided a lot of space for alignment. The function of the lip bumper is that it helps in altering the force distribution of the perioral musculature as well as the mucoperiostium so that the mandibular canines and premolars can become upright.^46,53,54

It is because of this process that the circumference of the mandibular arch gets increased because of which the crowded permanent dentition gets unraveled. The primary second molar space in the mandibular is the one which can be controlled by using a lip bumper, which would further prevent a mesial permanent molar drift. In this case distalization of upper molars can also be obtained. Relief in the mandibular arch length discrepancy as well as lateral arch development is achieved by regular transitional dentistry using appropriate biochemical principles.^{52, 55-57} There is less controversy in terms of correcting maxillary arch crowding than mandibular. Permanent maxillary first molars are moved distally and are maintained in the event that proper interdigitation is attained. The maxillary anterior apical region will also be enlarged through outward movement of the permanent maxillary canine because it creates much more space for lateral incisor roots.^56,57

A lot of times, the mesial angulation of the permanent maxillary canines and their distally positioned apices comes into a more stable situation in the maxilla once the distal movement of the canines takes place.^58,59

Timing is said to be the key in early treatment. This is because there is no point of allowing the abnormal functions as well as habits to develop into severe dental as well as jaw discrepancies in case of a growing child.¹² There is also no point in developing an arch length discrepancy at the time of the transitional dentition. In this case it is said that most of the times both the diphasic as well as the triphasic treatment looks a lot more logical as well as sensible. If there happens to be an early intervention in case of an arch length discrepancy then it can help in eliminating any need for the extractions of the premolars in the future.^{12,13,14,45,55}

The quality of the treatment in an individual is improved by ensuring that the etiologic factors are eliminated which would help in restoring the normal growth.⁴ It would also help in the reduction of the severity of the skeletal dyplasia which would allow precise positioning of the tooth in the adolescent patients. However, when the facial growth ceases the treatment options for the patients also becomes very limited.⁴⁵ This is the reason as to why it is preferred that the proper diagnosis as well as the treatment planning is done at the early intervention. It is also important to establish a visual treatment objective or a VTO so that the establishment of the occlusion can be finalized. All the dynamic anterior-posterior, transverse, and vertical dimension corrections would be taken into account on a routine basis in case of an early treatment if it is done in a proper way. Therefore, the two most important aspects in early orthodontic treatment are time as well as growth.^60-63

B) CAMOUFLAGE TREATMENT

If a patient is nearing or the end of peak growth stage, any mild or moderate skeletal anomalies will then be treated with a camouflage treatment that will use fixed conservative modalities and is often combined with extraction to move teeth. This can be done to hide the skeletal anomaly.^{53, 55-57}

C) A COMBINATION OF ORTHODONTIC TREATMENT AND ORTHOGNATHIC SURGERY TO CORRECT THE MALOCCLUSION AND UNDERLYING SKELETAL DISCREPANCY

If the skeletal anomaly is extreme in a patient and the patient is said to be at the end of the growth period, dental malocclusion as well as skeletal anomaly will be treated using both orthodontics as well as orthognathic surgery.^1,4,17-19

There has been a study done in Japan that has indicated that there are many changes in MVBF after mandibular setback surgeries two years after the surgical procedure via intraoral vertical ramus osteotomy.⁶⁴

There was a longitudinal study involving a group of surgical patients with mandibular prognathism. The study included 39 men and 39 women as well as a control group consisting of 32 men and 36 women with class I relationship. Measurements of bite force as well as contact area were taken before treatment and one month before surgery. This was again taken up after an interval of 1, 3, 6,9,12 as well as the use of the dental pre-scale system. In this case both time dependents as well as linked factors were also examined using a linear mixed model. The study also helps determine that both the occlusal force and the contact area increase after the post-surgical evaluation period. Time dependent modifications in terms of MVBF were also seen to be very different in the sense that the p value <0.05 and the importance of increasing the overall contact area were also mentioned in the study to increase bite force post surgery.⁶⁴

In recent times a cross-sectional study was carried out in terms of the mechanical advantage of the muscle as well as biting points, range of motion, maximum isometric byte force, and electromyographic (EMG) activity levels in the anterior and posterior masticatory muscles were all recorded on different subjects across all time points. Subsequently, data obtained before and after completion of presurgical decompensation were compared. According to the results there was a lot of change in the force of the bite before and after surgery, but a much larger study is needed to confirm whether the results will be the same in all orthodontic procedures.¹⁷

OCCLUSAL BITE FORCE

Bite force is one of the indicators that talks about the functional state of the masticatory system caused by the modification of the action of the jaw muscles performed by craniomandibular biomechanics.⁴ This determination of individual bite forces is used in dentistry to understand the mechanics of mastication so that the overall effects of prosthetic devices are provided.⁵ Also, bite strength is considered to be extremely important in the overall diagnosis of disturbances in the stomatognathic system.^4,6,7,16,21

Measurements of occlusal bite force are made directly using a suitable transducer which is then usually placed between molars. It is a straightforward method of force assessment and is also considered to be the most convenient method in which submaximal force will be obtained. An alternative to this method is the indirect evaluation of the biting force using physiologic variables that are functionally related to force production.⁵ The electromyographic activity of the muscles of the jaw surface can be measured by the subcutaneous projection of the muscular belly.^7,8

It is through this process that the data obtained will help to provide an idea about the bite force. There were some investigations which showed that there is a linear relationship between the potentials for electromyographic activity as well as direct cutting force measurements that occur at the submaximal level.⁴ There are several different factors that have a direct impact in the measurement of cutting force. The variation in bite force values ​​may depend on a number of factors that relate to both physical as well as anatomical aspects of subjects. In addition to these factors, the accuracy of the bite force depends on the different mechanical characteristics that are given in the cutting force recording system.^4,5,8,9,23

PHYSIOLOGIC AND MORPHOLOGIC VARIABLES AFFECTING BITE FORCE VALUES

A)    CRANIO-FACIAL MORPHOLOGY

The maximum bite force varies with the facial morphology of individuals, including the ratio between anterior as well as poster facial height, mandibular tilt, and gonial angle. The force is said to reflect the geometry of the lever system in the mandible. If the roule is vertical and the gonial angle is acute, the elevators have a superior mechanical advantage.^{8, 21, 22,65,66,67}

A negative correlation was found between cutting force as well as mandibular inclination. The result of such studies is consistent with other studies in which the morphology of the long-faced cranio-face was related to smaller values ​​of the cutting force.^{21,24,65,66,67}

These researchers have also stated that there is a relationship between the bite force as well as the thickness of the muscle, the thickness of the masseter-temporal muscle and the morphology of the face. In relation to this another cross sectional study has suggested that the muscles of the masseter are thicker in those with a short face than those who have a longer face. Through these studies it was found that people with shorter faces have a stronger bite force.^20,65,66,67

B)    AGE

Aging process is the reason as to why a lot of muscle force is lost. However, the jaw closing force does increase with age as well as growth and remains constant to up to 50 years starting from 20 years however it does decline after the age of 50.^{7,21,27,68,69} Children between the ages of 6 to 18 have bite force related to age.^3,25,31,69 There have been a number of studies which have showed that the bite force decreases after 25 in females and after 45 in males.  It is to be noted that the bite force decreases with age specifically for women. ^{21, 31,37,69}

A methodological study had evaluated the different effects that age had on maximum bite force, average magnitudes of pressure, and occlusal contact areas in elderly in both the elderly as well as young people. Both the occlusal contacts as well as maximum bite force were seen to be larger in the senior groups than that of the young group. The value of the smaller average occlusal is more in the senior group. There is however no difference between the total occlusal force as well as the occlusal force distribution which is same in both the older and younger people due to the larger contact areas of the teeth. Even though the core value of these studies is relation between bite force and age, it is felt that the effect of age on this factor is pretty small.^67,69 A study conducted in Brazil focused on children between the ages of 9 and 10 and aimed to determine their morphological characteristics as well as their relationship to maximum force with body mass index. Occlusal features in these children were evaluated using intra oral assessment and body weight as well as height using balance. The study noted that there was no effect of occlusal features on chewing measurements, but body size was associated with bite force in children.⁶⁸ A longitudinal study conducted in Colombia in which both school children as well as adolescents stated that maximum bite force is a factor that is influenced by age, as well as gender. The aim of the study was to determine the effects of the maximum bite force of subjects who were of growing in age. In addition, the incisor molar bite force assessment was done for children as well as adolescents. The age groups that were taken into account included the ages of 7,9,12 and 15 years and the measurements for these age groups were measured once a year for 3 years. Results of the study stated that the maximum cutting force increased the value of p> 0.05 over time.⁶⁹ In addition, a study that was conducted in Saudi compared the bite force on primary as well as permanent teeth of children. The study took into account 215 patients and the maximum cutting force was assessed using a hydraulic auxiliary force gauge. The results showed a slightly higher bite in the case of the permanent tooth and a higher bite force in the case of the 6th tooth with a P6 value; The maximum bite force was also higher in male than in female patients.⁷⁰

C)    GENDER

It is said that the maximum bite force is a lot higher in the males than in the females. The higher muscular potential of the males is because of the anatomic differences.^{6-18, 25, 28, 29, 71}

The masseter muscles which are present in the males consist of 2 fibers that have a much greater diameter as well as sectional area than that of the females.^{4, 32, 67, 72} It has also been suggested that the hormonal differences that exists between the males as well as females have a huge contribution on the composition of the muscle fibers.⁷²

It has to be understood that the correlation between the maximum bite force as well as gender is not at all visible till 18 years of age. It is seen that the there is an increase in the maximum bite force in the growth and development stage without having any gender specificity.^37,69  In the post pubertal period, the increase in the maximum bite force is much greater in the males than in the females and in that period it becomes gender related.⁶⁹

A longitudinal study stated that the males have a larger bite force value because they have a larger dental size. Since the larger dental size gives a presentation of a larger periodontal ligament area therefore it can lead to a much greater bite force.^30,31 In relation to this, a study that was conducted during sleep by making use of bite force sensors that showed no difference between the bite forces of the males versus the females. This could have been because the number of subjects which were taken was smaller in this study and also because of the functional forces which occur at the time of nocturnal sleep. There are indeed some of authors who have stated that there is no significant gender effect, however, the majority of the authors still believe in the fact that there exists a difference between the bite force values of males as well as females.^15,69,73,74 A study was conducted on the Caucasian population of Croatia which talks further about the relation of maximum bite force with age and gender. The study took sixty Caucasian subjects who were between 15 and 18 years of age. These children had a balanced facial outline, a neutral occlusion as well as no previous orthodontic records. The bite force in these students was measured using a portable force gauge and the study results showed that there was an increase in the bite force of males with a value of 0.002, which was between 15 and 18 years. The gender difference was clearly visible only after the age of 18 with a value of p as 0.003.⁴¹

D)    PERIODONTAL SUPPORT OF TEETH

The loading forces at the time of mastication have been induced by the masticatory muscles that were controlled by the micro receptors of the periodontal ligament.^20,30,31,75 Therefore; a periodontal support that is reduced has the potential to reduce the threshold power of the mechanoreceptors function.^30,31 It is because of this that there may be some changes in the bite. Through this study it was observed that the bite capacity of individuals with a healthy periodontium was much higher than those with chronic periodontitis.³¹

The results of this study are consistent with those of other studies that have been conducted and talk about a positive relationship between reduced periodontal support as well as decreased bite strength.⁷⁵ In this aspect, a cross sectional study that was initiated indicates an association between cutting ability as well as periodontal position. However, it was found that both have little effect on each other.⁷⁶ In contrast, there have been a number of studies that have shown that any reduction in periodontal tissue does not support the range of cutting force in terms of a maximal strength in natural occlusion. Furthermore, it was stated that the reduced number of periodontal neural receptors would prove to be sufficient to provide a response mechanism in limiting bite force as well as chewing forces.^77-79

The differences in these studies were due to recording devices as well as measurement fields. In addition, the analysis that took place between the local biting force as well as the local remaining periodontal ligament regions was in the context of a single tooth, resulting in different results.

E)    TEMPOROMANDIBULAR DISORDERS AND PAIN

Temperomandibular disorders (TMD) are related to signs and symptoms that are associated with pain as well as functional structural disturbances that occur exclusively in the masticatory system as well as the muscles of mastication. It is a fact that the etiology of TMDs is said to be multifactorial. TMDs are defined based on various signs as well as symptoms. The most common of these are aspects of the temporomandibular joint as well as muscle pain, limited mouth opening, clicking, and crepitation.^{16,18,25,26,34,65,74}

Bite force has the potential to affect muscle function as well as the development of mastictory function. This measurement of bite force can prove extremely useful in the understanding of masticatory functions in patients who have TMD’s.

There have been a lot of individuals who have focused on the fact that whether or not the bite forces have an influence on the TMD patients. A lot of authors have found that the bite force in the TMD patients is lower than that of the healthier subjects.⁸⁰ In the TMD patients there is a presence of the masticatory muscle pain as well as the temporomandibular joint which plays a huge role in limiting the bite forces.^74,81

With respect to these studies there was another study which found that there is a positive relationship between the bite force as well as muscle tenderness in case of the TMJ pain. ^{16,18,25,26,32,34,65,74}

F)     DENTAL STATUS

The position of the teeth, along with tooth fillings, dentures, prosthetics, plays a very important role in the overall value of the biting force. In this aspect a positive relationship can be seen between the number of teeth as well as the position and maximum of the teeth, as well as the submaximal levels.³⁵ The number of teeth and its contact has a huge impact on the maximum bite force. A greater bite force on the posterior dental arch may mean that it depends on the contact number of the posterior teeth that are loaded at the time of the bite. This means that when the maximum cutting force level increases from 30% to 100%, the contact area will also increase.^82-85

Preliminary studies have stated that the number of occlusal contacts can be seen as one of the strongest determinants of action of both muscles as well as bite compared to the number of teeth.⁴ One study analyzed the force of in both molars in subjects with and without fillings. Subjects that had dental filling showed lower bite force in terms of incision area. On the basis of this study, it can be said that this may be due to the adaptive changes in dentition.³⁵

Other studies also compared those who had complete natural detention to show changes in fully toothed, fixed partial toothed, removable partial toothed as well as natural dentition. The bite force was highest in people with natural teeth and 80, 35 and 11% bite force respectively in other groups.Similarly, implant-supported and root-maintained overdentures, full dentures, and cutting forces in natural dentition groups have been compared. Subjects with dental implant supported overdenture show higher levels than others. The maximum cutting force was still the lowest compared to others in the implant groups.^90-93

G)   MALOCCLUSION

Most bite force studies include subjects that have a full set of teeth, angle class I molars and no dysfunction. However, it should be understood how facial bite morphology and malocclusions affect maximum bite force in conservative treatment planning.

Malocclusion is said to be related to reduced mastication power.^{2,4,11,41,43,58,69} This is why conservative treatment is required to improve function. It does not vary between types of angle classifications. Children with unilateral posterior crossbones are said to have least maximum force and a lower number of contacts than those without these malocclusions. There is usually no correlation between malocclusion as well as maximum cutting force. Subjects that have a malocclusion have maximum bite force often related to number of contact areas.^1,69,94

CHANGES IN OCCLUSAL BITE FORCE DURING ORTHODONTIC TREATMENT

According to the literature it can be understood that there are several different ways in which functional occlusion can be identified. The occlusal bite force is the main predictor of masticatory performance. Although, there are several indicators that have been used to assess the functional status of the occlusion, the occlusal bite force is seen as one of the primary predictors. A 10–20% variation in the nature of these occlusal contacts has been observed in maximum bite force in adults. The reduction in cutting power is due to malocclusion. Children who have unilateral posterior crossbite are known to have least maximum force cutting as well as a decrease in the number of contacts.^{9,11,13,42,61,94}

Several longitudinal studies have shown that the bite force in humans decreases after cross bite treatment, however, it was observed to increase after retention. There were also changes in bite forces as there were transient changes in both contact and support.^10,13,74

Another study observed changes in mean bite force in patients who had anterior crossbite in their primary teeth and it was observed that the bite force in crossbite was the lowest but increased after treatment. Furthermore, it was found that biting power increased after starting orthodontic treatment, which was measured before removal.¹⁵

The maximum reduction in OBF occurs at the time of a conservative treatment. Decreased force was noted in patients scheduled for surgery. However, in case of presurgical treatment, the severity of malocclusion increases and the occlusal contacts decrease. In this aspect, pain is considered one of the factors that limits maximum bite force in people.^17,20

Another study stated that pain had an effect on muscle activity despite the fact that it did not originate from the associated muscle or joint. Pain and discomfort caused by orthodontic devices, which led to a decrease in biting power before and after presurgical orthodontics. In most surgical cases, various types of bite changes have been observed at the time of routine conservative treatment.²⁰

A study that was conducted at the University of Jordan on orthodontic patients provided evidence about how occlusal bite strength changes during a 6-month period of orthodontic treatment using prescribed equipment. This study states that in the first month, the cutting force is reduced by 50% before treatment. Biting power was lost at the end of the first week, but it reached pre-treatment levels every 6 months. People’s pain perception was also assessed, due to which it was found that there is a relationship between pain and occlusal bite force. The pain was reported to be highest in the initial two weeks and subsided over the following weeks.⁹⁷

OBJECTIVES

The objectives of this study are:

1. To compare changes in OBF during orthodontic treatment at different intervals compared to those not undergoing fixed orthodontic treatment.
2. To compare changes in OBF between subjects treated by extraction protocol and those by non extraction protocol.

Hypothesis

 Null hypothesis (H₀):  Orthodontic treatment has no effect on changes in OBF

 Alternative hypothesis (H_A): Orthodontic treatment has a positive effect on changes in OBF

Operational Definitions

Occlusal bite force is the force which is produced by the action of the muscles of mastication which in turn are determined by the stimulus from the central nervous system, it will be measured in Newtons (N).

Mean maximum occlusal bite force in males is reported as 448.47 ± 191.82 N and 296.31 ± 116.79 N in females.⁹⁶

METHODOLOGY

Study Design:

A Quasi-experimental study.

Study Setting:

In the orthodontic department of the Dow university of health sciences.

-Dow Dental College

-Ishrat-Ul-Ebad Institute Of Oral Health Sciences

Study Duration:

1 year after approval of synopsis

Study Population:

The sample was selected on the basis of the following:

1. Inclusion Criteria:

For study group:

1. Subjects undergoing treatment with fixed orthodontic appliance
2. Age 15-30 years.

• Angle class I relationship.

1. Either gender.
2. No congenitally absent or missing permanent teeth.

For control group

1. Age 15-30 years.
2. Patients not undergoing any orthodontic treatment.

• Angle class I relationship.

1. Either gender.
2. No congenitally absent or missing permanent teeth.

2. Exclusion Criteria:

For treatment and control group

1. Presence of crossbite.
2. No previous orthodontic treatment.

• Multiple restored teeth

1. Temporomandibular joint dysfunction.
2. Craniomandibular anomalies or systemic muscle or joint disorders.
3. Craniofacial syndromes

• Compromised periodontal condition
• Any prosthetic replacement

Sample Size:

Following settings were made in order to calculate the sample size.

Power of test = 80%

Confidence Interval = 95%

Reference Pass version II Software

Mean & Standard Deviation of OBF in control group: 640.52 ± 254.07 N ⁹⁵

Mean & Standard Deviation of OBF in treatment group: 467.91 ± 181.09 N ⁹⁵

With mean difference 172.61 N.⁹⁵

Sample size calculated is 26 for each group

Due to patient attrition and the rate of loss to follow up 15% extra of the sample size was taken which is a total of 30 patients in each group.

30 subjects included in the control group

60 subjects included in the treatment group:

Treatment group (n=60)

Total sample size is 90 subjects

Sampling Technique:

The technique was purposive that is the subject recruited were not randomly selected; however, their selection was based on the researchers judgement for selection of the participants in the study. Each patient that came in opd was carefully examined and depending upon the case they were offered to be a part of the study. However, whether they agreed or not they would be given equal treatment facility. The selected subjects gave informed consent before being a part of the study.

This type of the sampling is cost effective and is a time saving technique.

Data Collection Procedure:

The study began after approval of synopsis. All patients coming for consultation in the orthodontic department were examined and each was thoroughly screened to provide them with a treatment plan. Selection for the treatment group was based on the inclusion and exclusion criteria. An informed consent form was given to each patient. After their consent, patients were included in our study.

A group consisting of in-house officers was chosen to act as a control group.

Each patient was given a written consent form and the procedure was explained to each subject before the recording process began.

For our research, each patient was instructed to sit upright and be positioned in the natural head position and then asked to bite on the BFG to their full potential as possible. BFG was used unilaterally between molars. A second attempt was made after the rest phase. A total of five readings were taken and then a mean was calculated. The maximum sampling time was 20 seconds. All force samples were logged; The maximum value was used as the maximum occlusal force. All measurements were performed by a single investigator. A proforma (enclosed on page no 63) in tabular form was filled according to the maximum value that was entered at each interval.

Occlusal bite force measurement was recorded before the start of the treatment. A 2^nd recording was made 1 week after the placement of orthodontic brackets.  The 3^rd measurement was made at the 3^rd month of treatment. The 4^th recording was done at the 6^th month of treatment. And the final reading was taken at the 9^th month of treatment.

TOOL FOR TESTING OCCLUSAL BITE FORCE:

Occlusal bite force was measured using an occlusal bite force gauge (warm springs, Fremont, California, USA), the validity of which has already been tested.⁹⁸ The device consists of a 100lb MBS-100-100S*c01 sensor with 150-160lb capacity, which is combined with a flat base and a flattened top on the sensor and is attached to a DQ-1000U and is calibrated in compression. The LV-1000 software  let us display, log and plot the data in real time on a computer digitally.

Study Variables

Dependent variable:  occlusal bite force

Independent variables:

1. treatment group
2. control group
3. time intervals

Statistical Analysis:

Collected data was subjected to statistical analysis using Statistical Package for Social Sciences (SPSS) Version 22 software and was described in terms of Mean and standard deviations for all quantitative variables. The mean difference between occlusal bite forces expressed as percentage reduction of the mean, was assessed using rANOVA test.

The mean difference in OBF between extraction and non-extraction subjects was evaluated by independent t-test. Significance was predetermined at the p < 0.05 level.

Study Time Line

Budget:

Result

Our study recruited 90 subjects, from which 60 subjects were in the treatment group while 30 subjects were enrolled in the control group.

Evaluating the results based on the mean to assess the difference in the treatment and control group, it was noted that the mean of the initial reading of treatment was 286.9 ± 57.4 N while of the control group was 285.40 ± 34 N. This shows the baseline for both the group was nearly same. Comparing the initial reading with the final reading, it can be observed the final reading mean for the treatment group was 312.17 ± 52.6 N while for the control group was 286.4 ± 34.37 N as shown in Table 1 and Table 2.

The study assessed the OBF of the subjects at six different intervals. First, an assessment was made at the beginning of the treatment to evaluate the OBF of each subject. This displayed that the majority of the patients had their occlusal force between the range 200 to 300 N with, maximum force reaching up to range of 400 to 500 N as shown in Table 3. Similar assessment was performed with the recruited control group subjects which showed similar results as shown in Table 4.

After the treatment started, their first occlusal biting force was recorded one week after the braces were fixed. It was observed that there was a sudden decrease in the occlusal biting force to the range of 100 – 200 N as shown in Table 5.

On the final reading the recorded results displayed an increase in the biting force of the subjects to the range of 300 – 400 N, which was even more than the initial force of the subjects before the treatment as shown in Table 6. However, the similar time interval readings were taken of the control group that showed no significant change and majority biting force was with the range of 200 to 300 N as shown in table 7.

Further, when the results were analyzed statistically, the independent t test as shown in Table 8 displayed that there was no significant difference between the two groups, extraction and non extraction except at the time of the final reading on the 9th month of treatment. Therefore, this indicates although there was no significant difference between the occlusal bite forces of extraction or non extraction cases before and during the treatment; however, the end result of the treatment provides a significant difference in the bite force of subjects treated with non extraction protocol.

In addition the means of the each group control and treatment as shown in Table 12 and Table 13 was compared through the rANOVA test to assess any significant difference. The results clearly displayed a significant difference in the treatment group with a p-value less than 0.05, and no significant difference in the control group with a p-value greater than 0.05. Hence showing that orthodontic treatment has a positive effect on the Occlusal bite force.

Discussion:

Orthodontic treatment is one of the main branches of dentistry which helps to align the teeth in the functional position to achieve better occlusion and facial aesthetics.¹ To assess the masticatory activity, the orthodontist used many types of indicators to measure the functional state of the occlusion such as the OBF that is the key indicator of the masticatory function. A bite force is a result of the elevating action of the jaw muscles that are governed by the nervous system. Coordination of multiple muscles, bones, and teeth at a time results in a specific bite force for each .^2,4

The key factors, which determine a bite formation are the number and size of the occlusal contacts.^4,41,100 One of the major causes of reduced functional occlusal force is malocclusion. People with posterior cross bites have shown a reduction in the occlusal force because of less number of occlusal contacts as compared to the people with normal occlusion.

The presence of the malocclusion limits the occlusal contact area; hence, patients tend to incline while biting as stated in the literature¹⁰⁰. This study was able to display in the results, the increase of the number of occlusal contacts as the treatment proceeded towards the end. Therefore, the increase in the occlusal bite force towards the end of the treatment was observed.

The maximum bite force seems to decrease during the treatment as per the authors. In a study, it was observed that there was a decrease in the bite force after orthognathic surgery. The studies showed that presurgical procedure causes an increase in malocclusion because the first step is decompensation followed by the alignment for establishing the occlusal contacts. Also, pain is another factor responsible for the decrease in the maximum bite force. As per the study, pain even though not originating from the joint or muscle is equally responsible for withholding any occlusal movements, which initiate the pain.^{17, 64, 103}

Studies have been conducted to evaluate the bite force before, during the first 6 months of the treatment and after the treatment; nevertheless, this study conducted brief research starting from the beginning of the treatment to the 9th month of the treatment. The study which evaluated the bite occlusal force over 6 month’s period did not find any significant difference in the bite force of the patient.⁹⁵ However, our research was extended by another 3 months that defined the beneficial effects of orthodontic treatment. The maximum bite force in the first week after the application of fixed appliances was reduced to 50 % of the initial force before the treatment which is also supported by another study. ⁹⁵ Further, in the 1^st month of treatment, the value remained lower than the initial value; however, it was increased since the previous value was taken in the first week after the application of the braces. As the time of the treatment passed, the biting force of the patient increased. It is suggested that during the initial period of the treatment, the patient was getting used to the new appliance in the oral cavity and pain of the pressure applied by the appliance caused a reflex response in the patient to avoid biting; hence, lead to a decrease in the biting force.⁹⁵ With time, the teeth are aligned and the patient gets adjusted to the appliance, which increases biting force. Some studies displayed an increase in the force after the removal of the appliance, as the patient was able to bite to the maximum level without any hindrance to the appliance in the mouth^{15, 20, 95,104}. Hence, this indicated the importance of teeth alignment that not only makes the subjects aesthetically presentable, but also enhanced occlusal function.

This displays that the placement of the fixed appliance causes a change in the occlusal bite force and gradually with the alignment of the teeth the occlusal force increases as the teeth are now in a more functional position. However, the control group did not show any significant difference in the time to time measurement of the occlusal force. This indicates that orthodontic treatment plays a major role in correcting the functional occlusal bite of the patient.

Furthermore, our study focuses on the comparison between two types of the treatment protocol, with or without extraction cases. There was no significant difference observed between the treatment protocols at the beginning of the treatment; hence, it was kept as a baseline. Both were displaying similar biting force; however, in the 9th month of treatment both cases presented with a significant difference in biting force with p-value 0.034. As per the distribution of the OBF, it can be observed that the non-extraction cases were successful in achieving the maximum biting force up to the 300- 400 N range while extraction cases were slightly less able to achieve the same range. It is suggestive that in the extraction cases, premolar is the main pillar of occlusion which is extracted to provide solid contact points for maximum biting force and functional occlusion. This was in contrast to results from other studies which showed that the bite force taken in different areas of the oral cavity did not affect OBF. ^{9, 29, 40-42, 100, 102}

The cases, which underwent extraction showed a decrease in the occlusal contact, which is one of the major reasons for decrease in the masticatory function and the occlusal force. The non-extraction displayed success in the adjustment of the occlusion while the extraction cases faced some difficulty recovering from a normal occlusion. Hence, this study supports our objective that there is a significant difference in the extraction and non-extraction cases to present with maximum biting force. Although, the occlusal force decreased at the beginning of the treatment because of the application of the fixed appliance; however, with time as the teeth get aligned for more occlusal contact this would lead to increase patient satisfaction while chewing on the food. This was supported by another study that showed that food intake ability is also dependant on maximum bite forces. According to this study, at least 20 teeth are must for an optimum occlusal bite. Nevertheless, in the case of comparison of only the residual teeth remaining, it can be observed that masticatory function can differ according to the area of tooth loss even if the number of residual teeth was similar. Hence, it could be more rational to compare the loss of posterior teeth than the total number of teeth.¹⁰⁷ Therefore, extraction decreases the maximum biting force; however, it still achieves maximum biting force more than the initial biting force indicating that treating malocclusion by orthodontic treatment has a positive effect on OBF regardless of the treatment protocol.

Furthermore, a study involving orthognathic surgery presented their data in three parts, pre-treatment, presurgical and post-treatment. The study performed a cross-sectional examination that deduced the result based on the 3 years post-treatment follow up of the occlusal force after the surgical therapy^{17, 64,102,106}. It demonstrated that, during the pre-treatment phase, force was almost similar to the post-treatment result while in between the force decreased due to derangement of the occlusion. However, unlike our study, this study failed to provide a significant result that supported the orthodontic treatment in improving the maximum occlusal force. However, our study provided significant data that upheld the alternative hypothesis and rejected the null hypothesis.

One of the limitations of the study is that gender comparison cannot be made because the treatment group and the control group mainly comprises of the female; hence, unbiased estimation of the outcome cannot be made between the male and female. However, studies have shown that male patients have maximum biting force, which can be observed in our study of who have higher values of biting forces while mostly females biting force ranges from 200 to 300 N. Studies have shown that males have higher muscle strength because the thickness of the masseter muscle is more in males than females; hence, the biting force is observed more in males than females.^{6,16,25,27,28,37,67,69,72}

Another limitation of our study was that age comparison could not be done as most patients reporting to the OPD for treatment ranged from 18-22 years of age indicating a trend towards late teens and young adults. Hence a comparison between different age groups during developmental stages could not be done. Studies have shown changes in OBF ranging from 8-68 years which showed an increase in occlusal bite force till 25 years of age in both men and women after which it significantly decreased in women but showed a lesser decline in men till 45 years.^{3,7,21,25,27,37,68,69,70}

Conclusion

In conclusion, our study was successful in displaying that there is a significant difference in the results of pre-treatment and post treatment of occlusal bite forces.

The recorded data of the treatment group at 6 different time intervals in comparison to the control group demonstrated that there was a fluctuation in the maximum biting force of each individual at different time intervals. The drop during the treatment clearly defined the effect of pain and adjustment towards the new appliance. An increase at the end of the treatment was suggestive of more occlusal contacts which could bear more force that was useful in mastication and gave better aesthetic results as the state of malocclusion improved.

Furthermore, there has been a debate on the treatment plans including extractions due to few orthodontists favoring extractions due to the concept of affecting facial appearance and losing sound teeth; however, some favored this in terms of improving the occlusion and creating extra space for the movement of the teeth. Our study, worked on similar cases to understand a clear difference between the two types of the treatment protocol. However, there was no significant difference seen between the two cases during the treatment. Nevertheless, a significant difference was observed in the 9th month of treatment, with non-extraction cases displaying a more average maximum biting force than the extraction case.

Various studies also supported our results, pointing out that removing premolars to set the occlusion reduced the surface area of the occlusal table; that is the contact points which lead to decrease in the masticatory force. However, the force at the end of the treatment was much greater than before the start of treatment in both cases as well as between extraction of 2 and 4 premolars. Hence, the maximum force in comparison to the initial stage increased but the non-extraction cases demonstrated far more increase in maximum biting force than extraction cases.

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DOW UNIVERSITY OF HEALTH SCIENCES

DEPARTMENT OF ORTHODONTICS

CONSENT FORM

OPD Reg No__________    Ortho Record No_____________   Date_______________

Patient Name________________________________   Age_______________________

Address________________________________________________________________

_______________________________________________________________________

Contact No_________________            Office__________________________________

I understand that Dr. _________________________________________ will use his/her best knowledge, skill and training expertise in my treatment.

I have been fully explained regarding

1. Nature of the problems of my teeth
2. The treatment plan, its different phases/requirements, potential risks and relapse
3. Cooperation of patients is necessary regarding oral hygiene maintenance, use and care of braces throughout the treatment otherwise caries or discoloration of tooth surface may result
4. The data obtained from the patient can be used for research purpose and university examinations
5. Regular visits are very important for the completion of the treatment; in case of missing appointments and noncompliance treatment may be discontinued
6. Treatment charges include down payment initially and monthly installments
7. Measuring occlusal bite force is not part of every routine visit and will be an extra 5-minute procedure performed at every 3 months

I have read and understood the above instructions and I will follow them

Patients/Guardian signature:                                            Doctor’s name and signature

­­­_________________________                                          __________________________

Professor Dr. Imtiaz Ahmed   BDS, FCPS, M.Orth, Head of the Department

Dr. Batool Ali BDS, FCPS, Head of the Department

DOW UNIVERSITY OF HEALTH SCIENCES

DEPARTMENT OF ORTHODONTICS

رضامندی فارم  رجسٹریشن نمبر  _____________    ریکاڈنمبر ___________  تاریخ ____________ مریض کا نام________________  مریض کی عمر_______________   ایڈریس____________________________________________________________________ رابطہ نمبر _____________________   دفتر ___________________________  میری سمجھ کے مطابقڈاکٹر­­­­­­­­­­­­­­­_____________________ لاج میں اس کی / اس کی بہترین علم ، مہارت اور تربیت کی مہارت کا استعمال کریں گے یہ وضاحت کر دی گئی ہے : 1.     میرے دانت کے مسئلے کی نوعیت2.     علاج کی منصوبہ بندی, ممکنہ خطرات اور لگتے3.     مریض کے تعاون ضروری ہےے بارے میں زبانی حفظان صحت برقرار رکھنےعلاج کے دوراندوسری صورت میںکے caries یا دانتوں کی discoloration کے نتیجے کر سکتے ہیں4.     مریض سے حاصل اعداد و شمار کی تحقیق اور یونیورسٹی کے امتحان کے لئے استعمال کیا جا سکتا5.     باقاعدگی سے دورے کے علاج کی تکمیل کے لئے اہم ہیںلاپتہ تقرریوں علاج کو روکنے کا باعث بن سکتی 6.     علاج کے الزامات نیچے inital ادائیگی شامل ہوں گے , اور ماہانہ قسطوں7.     occlusal bite force ماپنےروٹینعلاجکےحصہ نہیں ہےاور ہر 3 ماہ میںایک اضافی 5 منٹ کا طریقہ کار ہو جائے گا

میں نے اوپر بیان کی ہدایات پڑھ لی ہےاور میں نے ان کی پیروی کریں گے  والدین / سرپرستکے دستخطڈاکٹرکے دستخط  _______________________                           __________________

Professor Dr. Imtiaz Ahmed   BDS, FCPS, M.Orth, Head of the Department

Dr. Batool Ali BDS, FCPS, Head of the Department

PRO FORMA

Patient name:

Age:                                                                                       Gender:

Classification:                                                                     Treatment protocol:

Operator:

Checked by: