External Oblique Ridge Research Articles

Three-dimensional evaluation of mandibular lingula: Comparisons of skeletal angle classifications and growth patterns.

This study aimed to evaluate the position of the mandibular lingula (ML) in adult patients (aged between 18 and 35 years old) with different skeletal and growth patterns using cone-beam computed tomography (CBCT). Cross-sectional. Dentistry department of University. Subjects comprised CBCT images of 150 adult patients, including 300 rami. In total, 150 CBCT aged between 18 and 35 were selected and divided into three main groups of 50 samples based on their skeletal relationships (classes I, II and III). Patients were subdivided based on their growth pattern (vertical vs. horizontal), resulting in 25 samples per subgroup. Distances between the mandibular lingula and occlusal plane (ML-OP), sigmoid notch (ML-SN), external oblique ridge (ML-EOR), internal oblique ridge (ML-IOR), posterior border of the ramus (ML-PBR), inferior border of the ramus (ML-IBR), and horizontal and vertical distances to the mandibular foramen (ML-hMF and ML-vMF). One-way ANOVA variance analysis was employed to compare different angle classifications, and Bonferroni analysis was used for multiple comparisons. The Student's t-test was also used to compare growth patterns within each main group and genders within the subgroup. The study revealed statistically significant differences in the position of the mandibular lingula between different angle classifications, growth patterns, and genders. Class II samples showed a more anterior position of the ML, whereas Class III samples displayed a more posterior position of the ML. Patients with horizontal growth patterns and Angle Class III had a more posteriorly positioned ML. Gender differences were observed, particularly in Class I and Class III classifications, suggesting that gender may influence the variability of ML position in these specific classifications. The position of the mandibular lingula showed high variability among individuals with different angle classifications, growth patterns and genders.

Bone Shell Technique with Relocated Crestal Ridge Segment for Anterior Horizontal Mandibular Ridge Atrophy: A Case Series.

Horizontal and vertical ridge augmentation via the bone shell technique provides predictable outcomes. The external oblique ridge is the most-used donor site for bone plate harvesting, followed by the mandibular symphysis. The lateral sinus wall and the palate have also been described as alternative donor sites. This preliminary case series reports a bone shell technique that used the coronal segment of the knife-edge ridge as a bone shell in five consecutive edentulous patients (20 sites) with severe mandibular horizontal ridge atrophy and adequate ridge height. The follow-up period was 1 to 4 years. The average horizontal bone gains at 1 mm and 5 mm below the newly formed ridge crest were 3.6 ± 0.76 mm and 3.4 ± 0.92 mm, respectively. Ridge volume was sufficiently restored in all patients to enable implant placement in a staged approach. In 2 of the 20 sites, additional hard tissue grafts were required at implant placement. The advantages of utilizing the relocated crestal ridge segment are as follows: The donor and recipient sites are the same, no major anatomical structures are compromised, periosteal releasing incisions and flap advancement are not required for primary wound closure, and the risk of wound dehiscence is minimized due to reduced muscle tension.

Virtual reality simulation of panoramic radiographic anatomy for dental students.

This work aimed to utilize virtual reality (VR) in dental radiographic anatomical interpretation in junior dental students and test if it can enhance student learning, engagement, and performance. VR software for panoramic anatomy was developed. Sixty-nine first-year dental students were divided into a control group (lecture-based) and an experimental group (VR) to learn panoramic radiographic anatomy. Both groups were then tested on knowledge via a 20-question quiz. Student feedback on VR experience was collected via an online survey. There was a statistically significant difference between lecture-based and VR students in the correct identification of anatomical landmarks. Lecture-based students scored higher in identifying the ear lobe, hyoid bone, condylar neck, and external oblique ridge, whereas VR students scored higher in identifying zygoma (Chi-squared test, p<0.005). The VR group reported high evaluation on all perception items of the online feedback survey on their experience (Student t-test, p<0.005). Lecture-based students generally showed better performance in panoramic radiographic anatomy. Several structures were not correctly identified in both groups of novice students. The positive feedback of VR experience encourages future implementation in education to augment conventional methods of radiographic anatomy in dentistry with considerations to repeated exposures throughout undergraduate dental education.

Single linear miniplate versus rectangular grid plate in the treatment of mandibular angle fractures: A prospective, clinico-radiographic, comparative study.

Randomized Control Trial. A prospective, clinico-radiographic, comparative study was planned to evaluate the treatment outcome and postoperative complications in isolated mandibular angle fractures using 2.0-mm system single linear 4 hole with gap miniplate versus 4 hole rectangular grid plate, both stabilized with 4 8-mm monocortical screws. Thirty patients with isolated mandibular angle fractures were randomly categorized into two groups with 15 patients each. Group 1 patients were treated with single 2.0 mm × 4 hole linear miniplate along the superior border and Group 2 patients were treated with a 2.0 mm × 4 hole rectangular grid plate on lateral cortex of mandible. Pain, swelling, occlusion, bite force, maximum inter-incisal opening, intraoperative time, facial nerve injury, fracture stability, and postoperative complications were assessed and compared at regular intervals up to 12 months. There was no major difference in terms of treatment outcome in both systems and both were equally effective without any statistically significant difference in any of the parameters. None of the patients presented with any of the complications except for postoperative infection which was reported by 1 patient from each group at 3 months postoperatively and were managed conservatively. Both plating systems are equally effective; however, the rectangular grid plate could be a safe and effective alternative to the single miniplate when adaptation and fixation is not possible along the external oblique ridge of the mandible (e.g., fracture with bone loss along the superior border).

Comparison of Single Plate Transbuccal Fixation with Intraoral External Oblique Ridge Fixation in Mandibular Angle Fractures

Background: Mandibular angle fractures are treated by many open reduction and fixation techniques. Each technique has several advantages and disadvantages. The external oblique ridge fixation via introral approach versus transbuccal fixation and intraoral approach together were compared in this study. Objective: To compare the clinical outcomes of intraoral external oblique ridge fixation vs an intraoral transbuccal technique. A single miniplate fixation for the therapy of mandibular angle fractures.Material and Methods: A total of 180 angle fracture patients were randomly assigned to one of two experimental groups in this randomized control trial. Each group had 80 patients: group A and group B. On the first week, first month, and third month, all of the patients were followed up on to assess infection and malocclusion.Results: With an age range of 16 to 60 years, the average age of the 160 patients was 24.79 years (SD 6.855). At the end of three months, 12 (15%) of patients in group A and 7 (8.75%) of patients in group B had infection. At the last follow-up appointment, 2 (2.5%) patients in group A and 1 (1.25%) patients in group B both had malocclusion (03 months post-op). At the third month after using the Chi square test, the P-value for infection and malocclusion was negligible.Conclusion: The present study concluded that combination method (introral with transbuccal) can effectively treat mandibular angle fractures because it allows for easier plate adaption and placement of the plate in the mid neutral area, which reduces the risk of infection and malocclusion.

Accuracy and Technical Predictability of Computer Guided Bone Harvesting from the Mandible: A Cone-Beam CT Analysis in 22 Consecutive Patients.

This study assesses the accuracy and technical predictability of a computer-guided procedure for harvesting bone from the external oblique ridge using a patient-specific cutting guide. Twenty-two patients needing bone augmentation for implant placement were subjected to mandibular osteotomy employing a case-specific stereolithographic surgical guide generated through computer aided design. Differences between planned and real cut planes were measured comparing pre- and post-operative Cone Beam Computed Tomography images of the donor site according to six validated angular and displacement indexes. Accuracy and technical predictability were assessed for 119 osteotomy planes over the study population. Three different guide fitting approaches were compared. An average root-mean-square discrepancy of 0.52 (0.30-0.97) mm was detected. The accuracy of apical and medial planes was higher than the mesial and distal planes due to occasional antero-posterior guide shift. Fitting the guide with an extra reference point on the closest tooth performed better than using only the bone surface, with two indexes significantly lower and less disperse. The study showed that the surgical plan was actualized with a 1 mm safety margin, allowing effective nerve preservation and reducing technical variability. When possible, surgical guide design should allow fitting on the closest tooth based on both radiological and/or intra-oral scan data.

Outcome of Transbuccal and Transoral Technique in Open Reduction and Internal Fixation of Mandibular Angle Fractures

Background: Angle fractures have the highest percentage among mandibular fractures. It has many reasons like thinner cross section area, presence of third molar, muscle forces acting at the angle area and abrupt change of shape from horizontal to vertical rami. Aim: To determine the outcomes of trans-buccal and trans-oral technique in open reduction and internal fixation of mandibular angle fractures. Study Design: Randomized control trial. Methodology: Total of 194 patients were recruited and divided in two groups. All patients underwent general anesthesia. In trans-oral group incision line was on external oblique ridge, exposing the ridge, the 5 holes mono-cortical plate were twisted and adapted to the ridge contour and fixed with 4 mono-cortical 2mm diameter screws. While in transbuccal approach, the angle region was exposed trans-orally. Statistical analysis: The collected data was analyzed by using SPSS version 25. Chi square was applied with p-value of less than 0.05 as significant. Results: The result showed infection in trans-buccal group was 5.4% and in transoral group was 17.4%. Wound dehiscence in trans-buccal group was 2.2% while in transoral group was 10.9%. Plate or screw loosening in trans-buccal group was 1.1% and transoral group was 7.6%. Mal-union in trans-buccal group was 1.1% and in trans-oral group, it was 7.6%. Conclusion: It was concluded that the trans-buccal is an effective procedure in terms of infection, wound dehiscence, mal-union and plate/screw loosening in comparison to trans-oral approach. Keywords: Trans-buccal, Trans-oral, Infection and Wound Dehiscence.

One miniplate versus two miniplates in the fixation of mandibular angle fractures. An updated systematic review and meta-analysis

PurposeThe aim of this study is to compare the outcomes after using one miniplate fixation in the external oblique ridge versus two miniplate fixation for mandibular angle fractures. MethodsA systematic review of MEDLINE (via PubMed), Scopus and Cochrane Library database was performed (last search date: 04 February 2022) according to the PRISMA guidelines. The research question was addressed using the PICO criteria. Only comparative studies between the two techniques were included. Random-effects model meta-analyses were performed. ResultsSeventeen studies, comprising a total of 1667 patients, 846 undergoing one miniplate fixation and 854 undergoing two miniplate fixation for mandibular angle fractures were identified. No statistically significant differences were observed regarding surgical site infection (odds ratio [OR]= 0.94, 95% confidence interval [CI]: [0.69] – [1.28], p = 0.68, I2=0.00%), post-operative malocclusion (OR= 0.97, 95% CI: [0.53] – [1.18], p = 0.25, I2=0.00%), post-operative neurosensory dysfunction (OR= 0.67, 95% CI: [0.37] – [1.22], p = 0.19, I2=73.93%), pseudoarthrosis formation (OR=0.90, 95% CI: [0.58] – [(1.39], p = 0.63, I2=0.00%). Wound dehiscence was marginally less common in the one miniplate group (OR=0.52, 95% CI: [0.28] – [0.98], p = 0.04, I2=54.34%). The probability of scarring formation (OR=0.13, 95% CI: [0.05] – [0.32], p = 0.00, I2=0.00%) and hardware failure (OR=0.36, 95% CI [0.21] – [0.62], p = 0.00, I2=29.33%) were statistically significantly higher in the two miniplates arm. ConclusionOne miniplate fixation and two miniplates fixation of mandibular angle fractures have similar results regarding post operative infection, malocclusion, neurosensory dysfunction and pseudoarthrosis formation while wound dehiscence, hardware failure and scarring seem to be more common when two miniplates are used as a fixation technique.

CLINICAL APPLICATIONS OF SAFESCRAPER® IN MAXILLARY SINUS FLOOR ELEVATION AND RIDGE AUGMENTATION

Introduction. Although there is a wide variety of bone grafting materials for the augmentation of the deficient alveolar ridge, autogenous bone is still considered to be the gold standard. There are various methods for harvesting autologous bone grafts. Among these, Safescraper® is conveniently used as a harvesting device of autogenous cortical bone in oral Implantology and reconstructive surgery, ensuring high volumes of grafting material with a minimally invasive and predictable procedure. Purpose. The purpose of this presentation is to showcase the clinical applications of Safescraper® in various augmentation procedures and to review the existing literature for the evidence supporting its application in clinical practice. Materials and Methods. In the presented cases, Safescraper® provided surface-derived autogenous bone graft deriving from the maxillary tuberosity, the zygomatic buttress, the lateral sinus wall, the pyriform aperture of the nose, the external oblique ridge and the mandibular symphysis. The collected autogenous bone has been mixed either with xenograft, or autologous venous blood, or platelet-rich fibrin and used in procedures such as: Maxillary sinus floor elevation, Reconstruction of periimplant defects, Reconstruction of alveolar ridge defects with onlay autogenous blocks, or bone rings, Ridge augmentations using resorbable collagen membranes, titanium-reinforced non-resorbable membranes or titanium meshes, Ridge augmentations using the Khoury technique. Results. Satisfactory amounts of autogenous bone have been harvested in all cases. The bone harvesting procedure was swift, reliable and devoid of any complications. Conclusion. Safescraper® is an extremely useful, cost-effective and minimally invasive device for collecting bone to adequately cover the needs in autogenous grafts everyday clinical practice.

Assessment of Dimensional Ridge Changes After Augmentation Using External Oblique Ridge with or without Computer Surgical Guide

Assessment of Dimensional Ridge Changes After Augmentation Using External Oblique Ridge with or without Computer Surgical Guide

Socket Preservation Using Autogenous Bone Graft and Dentin Autograft after Surgical Removal of Impacted Mandibular third Molar – A Split-Mouth Study Design

Introduction: In our study, we have compared the efficacy of dentin bone graft for purpose of ridge preservation and have compared it with autogenous bone graft (ABG). A total of 15 patients were included in this study requiring extraction of bilaterally impacted third molar. On the one side, the socket was filled with processed dentin graft prepared after extraction of the third molar, and on the other side, the socket was filled with ABG harvested from external oblique ridge. The two were compared on the basis of various soft tissue and hard tissue parameters. Aims: This study aimed to evaluate and compare the efficacy of the dentin autograft with ABG for preservation of socket defect after removal of mandibular third molars clinically and radiographically. Materials and Methods: A total of 15 patients were included undergoing extraction for bilaterally impacted third molar. The socket on one side after extraction was filled with processed dentin from the same extracted tooth, and the other side of the socket was filled with ABG harvested from the external oblique ridge. Results: It was seen that dentin graft had the regenerative properties and showed potential for ridge preservation. Conclusions: Ridge preservation is essential for placement of implant and other prostheses. Preservation of ridge immediately after extraction bypasses the need for extensive ridge augmentation procedure. Hence, dentin graft can be used for this purpose as it has potential for bone regeneration.

Two-thirds anteroposterior ramus length is the preferred osteotomy point for intraoral vertical ramus osteotomy.

This study aimed to investigate the mandibular canal of ramus and design a suitable osteotomy line for intraoral vertical ramus osteotomy (IVRO) using cone-beam computed tomography (CBCT). Ninety patients were classified into class I, II, and III skeletal pattern groups. When extended from the horizontal base plane (0mm, mandibular foramen [MF]), with a 2-mm section interval, to 10mm above and 10mm below the MF, the following landmarks were identified: external oblique ridge (EOR), posterior border of the ramus (PBR), and posterior lateral cortex of ramus (PLC): IVRO osteotomy point. In the base plane (0-mm plane), the EOR-PBR distance of class III (34.78mm) and the IOR-PBR distance of class II (32.72mm) were significantly higher than those of class I (32.95mm and 30.03mm). Compared to the EOR-PLC distance, the designed osteotomy point (two-thirds EOR-PBR length) has a 3.49-mm safe zone at the base plane and ranging from 0.89mm (+ 10-mm plane) to 8.37mm (- 10-mm plane). The position at two-thirds EOR-PBR length (anteroposterior diameter of the ramus) can serve as a reference distance for the IVRO osteotomy position. Mandibular setback operations for treating mandibular prognathism mainly include sagittal split ramus osteotomy (SSRO) and IVRO. IVRO has a markedly lower incidence of postoperative lower lip paraesthesia than SSRO. Our design presented a reference point for identification during IVRO, to prevent damage to the inferior alveolar neurovascular bundle.

Split-Block Graft Versus Cortico-cancellous Block Graft for Horizontal Ridge Augmentation: Cone Beam Computed Tomography and Histomorphometric Study

Objective: The aim of this study was to compare the horizontal dimensional changes of split-bone block and cortico-cancellous block graft in horizontal ridge augmentation using Cone Beam Computed Tomography (CBCT). The quality of the regenerated bone in both groups was compared histologically and histomorphometrically. Material and methods: Twenty patients were randomly divided in two equal groups (n= 10): Split-bone block group which was harvested from the external oblique ridge or cortico-cancellous block graft group which was harvested from the mandibular symphysis. Pre-augmentation crestal ridge width was measured using bone caliper. CBCT scans were taken on the 2nd week and 4th month post-operatively to measure crestal and total horizontal ridge dimensions. A biopsy was collected from the regenerated ridge immediately before implant insertion on the 4th month post-operatively. Results: Pre-augmentation crestal bone widths of both groups were comparable (P= 0.870). On the 2nd week and 4th month post-operatively, split-bone block showed a significantly wider crestal (P= 0.028 and P= 0.001 respectively) and total horizontal ridge dimension (P= 0.025 and P= 0.002 respectively), and on the 4th month post-operatively, it showed significantly lesser resorption at crest (P= 0.040) and in total horizontal ridge dimension (P= 0.017) than cortico-cancellous block. Histologically, the regenerated bone quality was similar in both groups. Histomorphometric analysis showed a non-significant difference in percentage of mature (P= 0.365) and immature collagen (P= 0.531) between both groups. Conclusion: Split-bone block maintained a significantly wider ridge and experienced less resorption after 4 months than the cortico-cancellous block graft, with no difference in regenerated bone quality between both groups. Keywords Dental implants; CBCT; Cortico-cancellous block graft; Histomorphometric analysis; Split-bone block technique.

Addendum

Addendum

Comparing treatment outcomes of external oblique ridge plating and lateral cortical plating for mandibular angle fractures

Aim: The aim of this study was to compare the outcomes of external oblique ridge platting and lateral cortical plating for mandibular angle fractures. Materials and Methods: A retrospective study was performed of patient’s data, who underwent open reduction and internal fixation of mandibular angle fractures. Inpatient and outpatient records were reviewed for pertinent data including age, gender, presence of other fractures, type of plating, operative time, and post-operative complications. Results: 40 patients with angle fracture were included in the study, 60% of them were treated with external oblique ridge plating and the rest 40% with lateral cortical plating. The mean age of the patients were 32.40 years. Main etiology of injury was road traffic accident (RTA). Post-op infection and wound dehiscence was observed in 12.5% and 10% of cases respectively in the external oblique plating group and 2.5% and 5% cases respectively in the lateral cortical plating group. Nonunion was not seen in any of the cases. Implant retrieval was performed in 5% of the external oblique ridge plating group and none in the other group. (p value 0.21). Conclusion: Lateral cortical plate fixation for angle fracture is a better and simple method when compared to external oblique ridge fixation. It is safe and reliable with minimal complications. Hence this technique is recommended for the fixation of mandibular angle fractures for better stability and outcome. Keywords: Mandibular angle fracture, External oblique ridge plating, Lateral cortical plate plating, Postop infection, Breakage of plate, Implant retrieval.

Comparison of Intraoral External Oblique Ridge Fixation and Transbuccal Lateral Cortical Plate Fixation for Mandibular Angle Fracture – A Randomized Control Trial

Background/objectives: Mandibular fractures account for almost half of all the fractures occurring in the maxillofacial region. Among mandibular fractures, angle fracture has a highest rate of post-operative complications (0-32%). This study compared the fixation of mandibular angle fracture with intra-oral external oblique ridge fixation versus transbuccal lateral cortical plate fixation using a single miniplate. Post-operative complications especially infection was noted and compared. Methods: A randomized controlled trial was done to compare the outcome of the two procedures. A total of 120 mandibular angle fracture patients were randomly allocated into Group A and Group B, 60 in each group. Group A underwent ORIF with intraoral approach and Group B underwent open reduction Internal fixation (ORIF) with transbuccal lateral cortical plate fixation for mandibular angle fractures. Patients of both groups were reviewed on 1st week, 1st month and third month for clinical signs of infection. Results: In group A, 10 (16.66%) patients suffered from infection and in group B, 4 (6.66%) of patients reported with infection at the last follow up visit that is at the end 3 months. No statistically significant p value after application of ‘Chi square test’ was noted for infection at the end of the third month review. Conclusion: Mandibular angle fractures can be effectively treated with transbuccal lateral cortical plate fixation as ease of plate adaptation, placement of plate in mid neutral area and less chance of infection.

Decisions Before Incisions: Technique Selection for the Distal Wedge Procedure.

What factors identify the optimal surgical technique when a distal wedge procedure is indicated at a terminal maxillary or mandibular molar site? Incision design for the distal wedge procedure is based primarily on the dental arch (maxilla or mandible), the distance from the terminal molar to the hamular notch or ascending ramus, and the dimensions of the attached gingiva. In most situations, favorable clinical results are achievable irrespective of the chosen distal wedge method, and technique selection is based more on operator preference than evidence. However, anatomic limitations can render distal wedge procedures challenging in some cases, and procedural advantages of specific techniques can simplify treatment. One systematic approach to distal wedge technique selection is presented in this report. Additionally, a laser-assisted distal wedge protocol is presented for cases in which unfavorable tooth-to-ramus distance or presence of a prominent external oblique ridge contraindicates conventional distal wedge techniques.

Dimension and Location of the Mandibular Lingula: Comparisons of Gender and Skeletal Patterns Using Cone-Beam Computed Tomography.

Objective The study aimed to investigate and measure the anatomical relationship between the mandibular lingula (Li) and skeletal patterns using cone-beam computed tomography (CBCT). Materials and Methods. In total, 72 participants (23 men and 49 women) were categorized into three groups according to their skeletal patterns (specifically, the A point–nasion–B point (ANB]) angle) as follows: Class I (0° < ANB < 4°), Class II (ANB ≥ 4°), and Class III (ANB ≤ 0°). The CBCT images of 144 rami were collected, and the distance from the Li to the external oblique ridge (Li-EOR), internal oblique ridge (Li-IOR), posterior border of the ramus (Li-PBR), inferior border of the ramus (Li-IBR), sigmoid notch (Li-Sm), and mandibular foramen (Li-MF) was examined. The Li-hMF (horizontal distance from the Li to the MF) and Li-vMF (vertical distance from the Li to the MF) were measured. The comparisons of gender, side (right and left), and skeletal patterns were then evaluated by statistical analysis. Results The values of the Li-EOR and Li-PBR (19.99 mm and 15.93 mm, respectively) were significantly higher in men than in women (18.85 mm and 14.89 mm, respectively). Moreover, the Li-IBR was higher in men (32.91 mm) than in women (30.40 mm). Both sides (right and left) and skeletal patterns demonstrated that the Li-EOR, Li-IOR, and Li-PBR were not significantly different. Pearson's correlation test reported a strong correlation between the Li-EOR and Li-IOR (r=0.610). Conclusion The distances from mandibula lingula to the external oblique ridge, posterior border of ramus, and inferior border of ramus were significantly longer in men than in women. Similarly, both horizontal and vertical distances from the lingula to the mandibular foramen were significantly longer in men than in women. Therefore, the results demonstrated that the Li was longer and more protruding in men than in women. With respect to the horizontal distance from the mandibular lingula to the mandibular foramen, of the three types of the skeletal system (Class I, Class II, and Class III), Class III was the significantly largest.

Mandibular Canal Position in Posterior Mandible: Anatomical Study and Surgical Considerations in Relation to Bone Harvesting Procedures.

The aim of this study is to evaluate the anatomical characteristics of the posterior region of the mandible and their surgical relevance related to bone harvesting procedures. Fifty retromolar cone beam computed tomography scans were analyzed considering the donor site anatomies. For each site, linear measurements were taken of cross-sectional scans to record perpendicular distances between the mandibular canal (MC) and the vestibular and crestal bone walls. Data showed that the distance from the MC to the vestibular bone wall is lower in the ramus area than in the external oblique ridge area (< 2.00 mm in 26% of cases). However, the distance between the MC and the crestal bone wall is higher in the ramus area than in the external oblique ridge area. There is less bone thickness in the ramus area, and this could expose the inferior alveolar nerve to damage if osteotomies are performed with fewer depth limitations, as reported in the literature.

Camouflage of Skeletal Class III Malocclusion in an Adult Male Using Miniscrew Anchorage From the External Oblique Ridge in Conjunction With Face Mask Wear

This article reports the successful camouflage of skeletal Class III malocclusion in a 20-year-old man through distalization of the mandibular dentition using miniscrew anchorage from the external oblique ridges of the mandible. In addition, maxillary face mask wear assisted in the closure of maxillary spacing without retroclination of maxillary incisors. This combination may be effective in the management of adult Class III skeletal malocclusions that are amenable to camouflage therapy.