Magnitude of Orthodontic Forces and Rate

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ORIGINAL ARTICLES

Magnitude of orthodontic forces and rate of bodily


tooth movement. An experimental study
Jack J.G.M. Pilon, DDS, a Anne M. Kuijpers-Jagtman, DDS, PhD, b and
Jaap C. Maltha, PhD °
Nijmegen, The Netherlands

The relationship between the magnitude of a constant continuous orthodontic force and rate of
bodily tooth movement was studied. In 25 young adult male beagle dogs, lower third premolars
were extracted and bone markers were implanted in the mandible. Sixteen weeks later, an
orthodontic appliance was placed, and elastics exerting 50, 100, or 200 gm were attached to the
lower second premolar to produce bodily distalization. In each dog, different forces were used on
the left and the right sides. As a control group, orthodontic appliances were placed without elastic
on eight sides. Tooth movement was measured directly with a digital caliper twice a week during 16
weeks. Resulting curves could be divided in four phases. Large individual differences were found
in the rate of tooth movement. Tooth movements on the left and right sides of each dog, however,
were highly correlated. No significant differences in the duration of each phase nor in the mean rate
of tooth movement during each phase were found between the three force groups. Maximum rate
of tooth movement was about 2.5 mm per month in all force groups. There were no significant
differences in the mesial movement of the anchorage unit between the force groups. It is concluded
that under the circumstances of this study magnitude of force is not decisive in determining the
rate of bodily tooth movement, but individual characteristics are. (Am J Orthod Dentofac Orthop
1996;110:16-23.)

I n orthodontics, no consensus exists on range for tooth movement exists, related to the root
how to move teeth most efficiently. An optimal surface area. 5 Most interesting is the relationship
approach should result in the highest possible rate between magnitude of pressure in the periodontal
of tooth movement without irreversible damage to ligament and the rate of tooth movement. A linear
the periodontal ligament, the alveolar bone, or the relationship may exist up to a maximum rate of
root. The formation of cell-free areas in the peri- tooth movement that cannot be increased by fur-
odontal ligament cannot be avoided, even with light ther increase of force. 6'7
forces. 1 Hyalinization occurs less frequently during Experimental studies on tooth movement are
bodily tooth movement than during tipping move- often difficult to interpret because the description
ments, 2 because forces are more evenly distributed of orthodontic forces is not uniform and incom-
along the root surface during bodily movement. plete. Another problem is that in earlier studies
In experiments using cats, large individual particularly, tipping movements were investi-
variations in the rate of bodily tooth movement gated, 79 where the tooth crown is used as a refer-
were found after application of identical forces. 3 ence point for measuring tooth movement. The
These differences could be attributed to bone den- results of these studies are hard to interpret be-
sity, supraalveolar fibers, structure of collagen fi- cause the relation between the rate of crown and
bers, and cellular activity in the periodontal liga- root movement is dependent on the position of the
ment. 3'4 It was suggested that an optimal force center of rotation that is difficult to determine and
probably changes during tipping tooth movement. TM
Not only is the question of the relationship
From the University of Nijmegen, Faculty of Medical Sciences, Depart- between the force magnitude per unit of root
ment of Orthodontics and Oral Histology. surface area and rate of tooth movement not an-
"Orthodontist, in private practice. swered, but equally important is a reliable registra-
bProfessor of Orthodontics, Department of Orthodontics and Oral His-
tion of time-displacement curves of orthodontic
tology.
CAssociate Professor of Oral Biology, Department of Orthodontics and tooth movement over a period longer than 4 weeks.
Oral Histology. This has never been done. The purpose of this
Reprint requests to: Dr. J. C. Maltha, University of Nijmegen, Depart- experiment is to study the relationship between the
ment of Orthodontics and Oral Histology, Philips van Leydenlaan 25, magnitude of a constant and continuous orthodon-
6525 EX Nijmegen, The Netherlands.
Copyright © 1996 by the American Association of Orthodontists. tic force and the rate of bodily tooth movement
0889-5406/96/$5.00 + 0 8/1/59442 during a period of 16 weeks.
16
American Journal of Orthodontics and Dentofacial Orthopedics Pilon, Kuijpers-Jagtman, and Maltha 17
Volume 110, No. 1

MATERIALS AND METHODS Table I. Number of dogs (n) with the forces (gin)
Experimental set-up applied to the second premolar on the left and
right sides. Forces were selected at random for
A group of 25 young adult male beagles was used,
the left and right sides
including eight pairs of twin brothers and one triplet.
The age of the dogs varied between 1 and 1.5 years. After Force
extraction of the mandibular third premolars, bodily
Side 1 Side 2
distalization of the lower second premolars was pro-
duced. The sides were divided into four groups: control 3 0 50
sides (n = 7) in which the appliances were placed and no 2 0 100
force was exerted and three experimental groups of sides 2 0 200
in which 50 gm (n = 16), 100 gm (n = 14), and 200 gm 6 50 100
6 50 200
(n = 14) was applied. In total, 44 sides were present in 6 100 200
the experimental groups: one former control side (0 gm)
was added to the 50 gm group, one to the 200 gm group,
and on one side, the 200 gm appliance was lost. On the distal side of the buccal tube at the fourth premolar were
left and right sides of each dog, different forces were prepared parallel to each other. They were used as
used which were selected at random (Table I). reference planes for the measuring procedure.
While the dogs were anesthetized, the enamel was
Surgical procedures polished and etched, and the appliances were cemented
The dogs were premedicated with 1.5 mL Thalam- with Panavia Ex Dental Adhesive (Cavex Holland BV,
onal (fentanyl 0.05 mg/mL and droperidol 2.5 mg/mL; Haarlem, The Netherlands) at the left and right sides of
Janssen Pharmaceutica, Beerse, Belgium) and anesthe- each dog. During the experimental period of 16 weeks,
tized with Nesdonal 15 mg/kg (thiopental sodium 50 elastics (Ormco Z-pak elastics, Glendora, Calif.) were
mg/mL; Rhone-Poulenc Pharma, Amstelveen, The Neth- attached from a buccal hook on the second premolar
erlands). The lower left and right third premolars were crown to a buccal hook on the fourth premolar crown.
extracted after hemisection. Before the start of the Because elastics show a great loss of force after initial
experimental tooth movement, while the dogs were un- extension, they were prestretched before experimental
der general anesthesia, three tantalum bone markers use. In this way, they kept a more constant force level for
(Ole Dich, Hvidovre, Denmark) were implanted on both more than 2 weeks. '2 Forces were measured twice a week
sides of the mandible according to the method of Bj6rk? ~ with a strain gauge. New prestretched elastics were
attached when a deviation of more than 5% of the
Orthodontic procedure desired force level was registered. The orthodontic ap-
Sixteen weeks after extraction of the third premolars, pliance, teeth, and gingiva were thoroughly cleaned twice
alginate impressions (CA 37, Cavex Holland BV, Haar- a week with a toothbrush and gauzes soaked with 0.02%
lem, The Netherlands) of the lower dental arches were chlorhexidine in water.
made after sedation with 1 mL of a preparation contain-
Radiographic procedure
ing 10 mg oxycodon HC1, 1 mg acepromazine, and 0.5 nag
atropine sulfate, which was injected subcutaneous. The Every 2 weeks, standardized oblique lateral radio-
impressions were poured in stone (Silkyrock Violet, graphs of the left and right sides of the lower jaw were
Whipmix Corporation, Louisville, Ky) within a few hours. taken while the dogs were under general anesthesia. The
On the dental casts, an appliance was constructed allow- dogs were fixed in a cephalostat according to Maltha 13
ing bodily distalization of the second premolar (Fig. 1). with two earrods and a pin in the midsagittal plane. The
Crowns were modeled in wax on the second and fourth x-ray film (Kodak dental x-ray speed photo, Kodak BV,
premolar and onlays on the distal concave surface of the Driebergen-Rijsenburg, The Netherlands) was placed in
canine and the lingual surface of the permanent first a standardized position, perpendicular to the central
molar. The canine, fourth premolar, and first molar were x-ray, at a distance of 5 cm behind the side of the
connected with a lingual bar to serve as an anchorage mandible. The focus-film distance was 3 m. A Phillips
unit. The appliance was casted in a chrome-cobalt alloy Practix X-ray machine (Philips, The Hague, The Neth-
(Wironium Bego, Bremen, Germany) and the inner sur- erlands) was used set at 20 mA, and 90 kV with an
faces were etched to improve retention. At the buccal exposure time of 4 seconds. After exposure, films were
side of the second premolar crown, a rigid sliding wire processed in a R.P.X Processor (Kodak) for 90 seconds.
(316 chrome-nickel stainless steel) with a diameter of
2 mm was soldered. At the buccal side of the fourth Measurements
premolar crown, a ring was modeled into which a round Twice a week, the distance between the reference
steel tube was glued (Uhu epoxy glue, Beecham, Milan, points on the orthodontic appliance was measured in-
Italy). The inner diameter of the tube was 0.02 nun larger traorally with a digital caliper. For each measurement,
than the sliding wire at the second premolar. The mesial the dogs were sedated as described previously. Each
end of the sliding wire at the second premolar and the time, three successive measurements were made, which
18 Pilon, Kuijpers-Jagtman, and Maltha American Journal of Orthodontics and Dentofacial Orthopedics
July 1996

C P2 P4 M1

J
~- . . . . . . . . . . . . . . d___4~ J

B1 Q B2

Fig. 2. Schematic drawing of radiographic image. Center of


tube on fourth premolar was defined as intersection of two
diagonals. This point was projected (Q) on line connecting
centers of two bone markers (B1 and B2). Distance B1-Q was
used to determine loss of anchorage in relation to bone
markers.

was shown to be negligible.TM Double measurements of 31


radiographs were performed to determine the intraob-
server differences. Changes in distance B1-Q and B1-B2
between the force groups were studied with an analysis
of variance (ANOVA).
Time-displacement curves of total tooth movement
were plotted for each experimental side. It appeared that
these curves could be divided into four phases. Two
Fig. 1. Orthodontic appliance to produce bodily distalization independent observers scored the end of each phase and
of second lower premolar. Canine, fourth premolar, and first interobserver agreement was evaluated. For each phase,
molar are connected with lingual bar to serve as anchorage the duration in days was determined. The relationship
unit. A: Buccal view, B: occlusal view. between the magnitude of the orthodontic force and the
duration of each phase was studied with ANOVA. Pear-
were averaged for the definitive score. The radiographs son correlation coefficients were calculated between
were digitized on an electronic measuring table. The four mean rates of tooth movement during phase 1, 2, 3, and
angular points of the rectangular projection of the buccal 4. A combined t test was performed for each phase to
tube on the fourth premolar crown and both ends of two compare the results of the independent samples with the
of the bone markers were recorded. The center of the paired samples.
tube was defined as the intersection of the two diagonals. The changes in the distances are the result of the
This point was projected on a line connecting the centers distal movement of the second premolar and the mesial
of two bone markers (B1 and B2) (Fig. 2). The distance movement of the anchorage unit. Differences in mean
between this projection point (Q) and the center of the loss of anchorage were compared between the different
mesial bone marker (B1) was used to determine the loss force groups by studying distance B1-Q with ANOVA.
of anchorage in relation to the bone markers. Changes in The percentage of the total amount of tooth movement
the distance between the centers of the mesial and the during each phase that was caused by mesial movement
distal bone markers (B1-B2) were verified. Every 2 weeks of the anchorage unit was compared between the force
the dogs were weighed. groups with A N O V A and between the phases with the
Student t test. Pearson correlation coefficients were cal-
Statistics culated to study the relationship between the amount of
To assess the reproducibility of the measuring movement of the second premolar and the loss of an-
method, 54 measurements were carried out twice within chorage. For each phase, Pearson correlation coefficients
half an hour by two independent observers. Differences for rate of tooth movement between the left and right
were tested by calculating the standard deviation of the sides of each dog were calculated. The results of two
mean difference. groups of brother dogs were compared with intraclass
The error of the method for the radiographic study is correlation coefficients.
made up of an error due to inexact positioning of the dog The means from the first three and the last three
in the cephalostat and a measurement error. In a previ- weights of the experimental period were compared (Stu-
ous study the error of the radiographic procedure itself dent t test).
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 110, No. 1
Pilon, Kuijpers-Jagtman, and Maltha 19

mm mm
8 8-1

6 dog 1
100 g

dog 2
4 100 g
4

dog 3
1 1 100 g
I/2
0 ~ ' ~ ! i , [
0 20 40 60 80 100 120 0 20 40 60 80 1 O0 120
days days
Fig. 3. Example of tooth-displacement curve divided into four Fig. 4. Time-displacement curves of experimental sides of
phases. Phase 1 = initial tooth movement, phase 2 = arrest three different dogs with force of 100 gm.
of tooth movement, phase 3 = acceleration of tooth move-
ment, and phase 4 = constant linear tooth movement.
measuring points were found. In these cases, a
consensus was arrived at.
In Table II, the mean duration of phase 1, 2,
RESULTS and 3 is presented. In 75% of the cases, phase i
General considerations
lasted 3 or 4 days or less and its duration was never
The measuring technique with the digital cali- longer than 7 days. The arrest of tooth movement
per was proved to be accurate, as the standard during phase 2 for all force groups lasted an aver-
deviation of the mean difference between two ob- age of about 7 days. In 27% of all cases, phase 2
servers was 0.02 mm. In the radiographic proce- was absent, and continuous tooth movement from
dure, the error in distance B1-Q was 0.18 mm and the beginning to the end of the experiment was
intraobserver differences were negligible. The bone observed. In 23% of all cases, the acceleration of
markers were proved to be stable as no significant tooth movement during phase 3 lasted until the end
change in distance B1-B2 was found. The weight of the experiment; these cases are not listed in
curves showed a regular increase during the experi- Table II. No relationship was found between the
mental period and a significant weight gain of duration of phases 1, 2, or 3 and the magnitude of
0.71 _ 0.93 kg was found (p < 0.01). the force (ANOVA, p _ 0.1).
Between the force groups of 50, 100, and 200
Tooth movement
gm, no significant differences in mean rate of tooth
Individual time-displacement curves were di- movement were found during any phase (ANOVA,
vided into four phases (Fig. 3). Transition from one p _> 0.1, Table III). However, a positive correlation
phase to another in most instances was clear and was found between the rate of tooth movement
scores of the two observers were mostly identical. during phase 1 and the magnitude of the force
Only for the transition from the acceleration phase (Pearson 0.33, p < 0.05). Mean total tooth move-
(phase 3) to the phase of linear tooth movement ment during phase I was 195 Ixm for 50 gm and 280
(phase 4), differences of one or sometimes two t~m for 200 gm. The combined t test showed that no
20 Pilon, Kuijpers-Jagtman, and Maltha American Journal of Orthodontics and Dentofacial Orthopedics
July 1996

Table II. Mean duration (days) and SD of the initial phase (1), phase of arrest of tooth movement (2), and
acceleration phase (3) of the second premolar for forces of 50, 100, and 200 gm
Force

50 100 200

Phase n Mean SD n Mean SD n Mean SD

1 16 4.2 2.0 14 4.0 1.9 14 4.5 1.9


2 16 7.9 9.2 14 7.3 6.7 14 7.1 8.2
3 13 36.6 23.4 11 35.6 21.6 10 38.2 21.5

No significant differences in mean duration of phases 1, 2, and 3 between the force groups (ANOVA, p _> 0.1).

Table III. Mean rate of tooth movement (txm/day) and SD for the forces of 50, 100, and 200 gm during the initial
phase (1), arrest of tooth movement (2), acceleration phase (3), and linear tooth movement (4)
Force

50 100 200

Phase Mean SD n Mean SD n Mean SD

1 15 46.4 19.0 13 52.3 14.1 14 62.5 25.9


2 12 2.8 5.5 10 2.1 13.0 9 0.5 7.5
3 15 23.6 10.8 13 23.5 9.4 13 22.7 10.8
4 13 59.3 14.8 11 63.8 19.6 10 62.7 22.1

No significant differences in mean rate of tooth movement during phases 1, 2, 3, and 4 between the force groups (ANOVA, p ___ 0.1).

differences exist between the independent and and 4 and also the duration of phase 2 were
paired samples in each phase. In the control group compared between the left and the right sides of
(0 gm), the mean amount of tooth movement over each dog. A significant correlation between both
the whole experimental period was 2 p.m. sides was found for mean rate of tooth movement
A large individual variation was found for the during phases 3 (p < 0.05) and during phase 4
mean rate of tooth movement in all force groups. (p < 0.01, Table V). Time-displacement curves of
Differences in individual reaction are illustrated in the left and the right sides of each dog usually are
the time-displacement curves of three experimental close together, independent of the magnitude of
sides in different dogs with the same force of 100 the force (Fig. 5). In some cases, a marked similar-
gm (Fig. 4). ity was found in the time-displacement curves of
Tooth movement during phases 3 and 4 is brother dogs (Fig. 6). Intraclass correlation coeffi-
continuous, without periods of arrest. Differences cients for brother dogs were lower than for the
in the maximum rate of tooth movement during left-right comparison but still significant for the
phase 4 between the force groups are not signifi- rate of tooth movement during phases 1 (p < 0.01)
cant; 72, 76, and 73 i~m/day for 50, 100, and 200 gm, and 4 (0.01 < p < 0.05) (Table V).
respectively. No significant correlation was found
DISCUSSION
between the individual mean rates Of tooth move-
ment for the different phases, except for phases 3 Since Reitan's experiments, 1'2'4'1.16 it is known
and 4, which were highly correlated (Pearson 0.69, that the structure and density of bone has an
p < 0.01). influence on the rate of orthodontic tooth move-
No significant differences in mesial movement ment. Although the alveolar bone of dogs is gen-
of the anchorage unit were found between the erally denser than in human beings, 16 differences
three force groups (ANOVA, p _ 0.05). Differ- between the anatomy of the periodontal ligament
ences in loss of anchorage as a percentage of the and alveolar bone of dogs and human beings are
total amount of tooth movement between phases 1, rather small and in this respect, beagles are gener-
3, and 4 were not significant. (t test, p > 0.05, ally accepted as a good model for comparison with
Table IV). human beings? 7 In this experiment, complete heal-
The rate of tooth movement during phases 1, 3, ing of the alveolar bone after extraction of the third
American Journal of Orthodontics and Dentofacial Orthopedics eilon~ K u i j p e r s - J a g t m a n , a n d M a l t h a 21
Volume 110, No. 1

mm mm
8~ 8~

7 dog 1
50 g
dog 1
200 g 6

dog 1
100 g
dog 2
200 g
4

dog 2
50 g

dog 2
200 g
T I I ' i 0 -# ~ ~ I

0 20 40 60 80 1 O0 120 0 20 40 60 80 1O0 120


days days

Fig. 5. Time-displacement curves of left and right sides of two Fig. 6. Time-displacement curve of experimental sides of two
different dogs. In dog 1 forces of 100 and 200 gm were used, twin brother dogs with forces of 50 and 200 gm.
in dog 2 forces of 50 and 200 gm.

Table IV. Mesial movement of the anchorage unit as a percentage (%) and SD of the total amount of tooth movement
for the force groups of 50, 100, and 200 gm during phases 1, 3, and 4
Force

50 100 200

Phase n Mean SD n Mean SD n Mean SD

1 15 10 38.7 11 2 33.2 13 8 50.5


3 15 38 89.1 11 38 56.4 12 30 45.0
4 13 21 21.6 8 16 19.8 8 21 19.8

No significant differences between the force groups (NOVA, p -> 0.1) nor between the phases (t test, p -> 0.05).

Table V. Pearson correlation coefficients for mean rate of tooth movement M (ixm/day) during phases 1, 3, and 4 and
for mean duration D (days) of phase 2 for the left and the right sides of each dog. Intra0:lass correlation
coefficients for rate of tooth movement for brother dogs

Brother-brother
Phase n L-R comparison n comparison

M 1 17 0.22 14 0.59**
D 2 18 -0.14 8 -0.42
M 3 17 0.50* 14 - 0.33
M 4 12 0.92** 9 0.56*

"0.01 -< p < 0.05; **p < 0.1.


22 Pilon, Kuijpers-Jagtman, and Maltha American Journal of Orthodontics and Dentofacial Orthopedics
July 1996

premolar was allowed, to provide an experimental rate of tooth movement between the force groups
site with a uniform bone structure. seem to indicate that there is a biologic limit for the
It can be concluded that tooth movement mea- rate of bodily tooth movement in beagle dogs.
sured in this experiment indeed is the result of the Independent of force magnitude, only incidentally
applied orthodontic forces, since no significant no change in tooth position was found between two
spontaneous tooth movement was measured in the consecutive measurements during phases 3 and 4.
control group where no elastics were attached. This This means that once tooth movement has started,
means that functional forces of tongue or cheek bone remodeling and periodontal ligament turn-
and biting forces do not contribute to the distal over takes place at a more or less constant rate.
movement of the second premolar. Also, contrac- The root surface area on the distal side of the
tion of transseptal fibers that might occur after second lower premolar in beagle dogs is estimated
extraction of the third premolar does not produce to be 0.5 cm 2. In the force groups of 50, 100 and 200
forces large enough to result in distalization of the gm, this would initially result in a pressure at the
second premolar. root surface of about 100, 200, and 400 grn/cm2,
The time-displacement curves of the three force respectively. Large differences exist in the optimum
groups show a comparable pattern. Phase 1 can be pressure advised by different authors: 250 to 300
interpreted as the initial movement of a tooth in its gm/cm2,21 200 to 250 gm/cma,2z 70 to 140 gm/cm:,6
socket. Because of the orthodontic force, the width and 80 gm/cm:.~3 In our study, however, no signifi-
of the periodontal ligament is reduced on the cant differences in rate of tooth movement between
pressure side. This movement is limited by hydro- initial pressures of approximately 100, 200, and 400
dynamic damping as is described earlier by Bien. 18 gm/cm2 could be found. The total root surface area
A large instantaneous movement will be followed of the anchorage unit is estimated to be 10 times
by a delayed reaction due to viscoelastic properties the root surface area of the lower second premolar,
of the periodontal ligament. With increasing force, so initial pressure in the periodontal ligament of
the initial tooth movement becomes larger. these teeth would be about 10, 20 and 40 gm/cm2
Phase 2 can be considered as a period of arrest for the three force groups. Also, in the anchorage
of tooth movement and is probably associated with unit, no significant differences in rate of tooth
hyalinization in the periodontal ligaments) 5 Hy- movement were found. So it seems that not only
alinization areas appear earlier and are more ex- with "high" pressures, but also with "low" pres-
tensive if higher forces are used. 19 Although the sures in the periodontal ligament, the rate of tooth
extension of these areas might be related to force movement is not closely related to force magnitude.
magnitude, this seems to have no clinical signifi- This indicates that no linear relationship exists
cance for bodily tooth movement in the present between the initial pressure in the periodontal
circumstances, as the duration of phase 2 was ligament and the rate of bodily tooth movement.
independent of the force magnitude. This may be The actual movement of the second premolar is
explained by the fact that during bodily tooth the difference between the amount of tooth move-
movement, forces are more equally distributed ment measured intraorally and the mesial move-
along the surface of the alveolar bone than during ment of the anchorage unit. Calculation of these
tipping, reducing the risk of hyalinization.2° A large differences, however, was not justified because of
individual variation was found in the duration of the relatively large difference in the errors between
phase 2, ranging from 0 to 35 days independent of the radiographic and the intraoral measurements
the applied force. This might indicate that differ- of 0.18 and 0.01 ram, respectively.
ences in bone density or in metabolic activities in Large individual differences in the rate of tooth
bone or periodontal ligament play an important movement were found in all force groups. This is in
role. agreement with previous studies in cats. 1 An expla-
Phase 3 is characterized by a continuous tooth nation could be that each individual animal has its
movement with an increasing rate. This accelera- own optimum pressure for tooth movement and
tion phase may be interpreted as a period in which that in the "slow movers," the optimum forces were
biologic processes involved in remodeling of the not applied. On the other hand, the results of the
periodontal ligament and alveolar bone reach their left and the right sides in each dog are highly
maximum capacity. This may also explain why, correlated, although different forces were applied.
subsequently, constant tooth movement is observed This might suggest that those "slow movers" were
in phase 4. The small differences in the maximum unable to move faster because of lower metabolic
American Journal of Orthodontics and Dentofacial Orthopedics Piton, Kuijpers-Jagtman, and Maltha 23
Volume 110, No. 1

capacity resulting in slower bone turnover. The 6. Boester C, Johnston L. A clinical investigation of the concepts of differential and
optimal force in canine retraction. Angle Orthod 1974;44:113-9.
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curves of brother dogs suggests a possible influence J Orthod 1985;88;252-60.
8. Hixon EH, Aaseu TO, Arango J. Optimal force, differential force and anchorage.
of genetic factors. The absence of such similarity in Am J Orthod 1969;55;437-57.
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1972;62:507-16.
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elastics. Eur J Orthod (in press).
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subsequent tooth movement. Individual differences in Nijmegen, The Netherlands: University of Nijmegen, 1982.
bone density, bone metabolism, and turnover in the 14. Wijdeveld MGMM, Grupping EM, Knijpers-Jagtman AM, Maltha JC. Growth of
the maxilla after soft tissue palatal surgery at different ages on Beagle dogs.
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Acta Odont Seand 1947;6:115-44.
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