Maxillary Left Central Incisor Research Articles

Management of a Complicated Crown Fracture in a Tertiary Care Hospital

Restoration of a fractured tooth is routinely performed in clinical practice. Many factors are considered in an effort to provide optimal mechanical properties, aesthetics, longevity as well as patient acceptance. In this type of challenging endeavour, main effort should be made to save as much of the coronal tooth structure to increase survival rate of endodontically-treated teeth. This case report presents a 35-year-old male with an oblique complicated crown fracture of maxillary left central incisor tooth. The procedure used to repair the fracture was gingivectomy followed by endodontic treatment. The root canal was filled with a root canal sealer and gutta-percha points. After root canal obturation, the tooth was restored with a glass fiber post and composite resin without additional crown coverage. The restoration made it possible to maintain the remaining tooth structure in a good occlusion and resulted in a high level of patient satisfaction.J Enam Med Col 2017; 7(1): 35-38

An Appraisal of the Prevalence and Attributes of Traumatic Dental Injuries in the Permanent Anterior Teeth among 7-14-Year-Old School Children of North East Delhi.

Aims:The aim of this study was to assess the prevalence, associated risk factors, characteristics, and pattern of traumatic dental injuries (TDIs) in the permanent anterior teeth among school children of North East Delhi area.Settings and Design:A cross-sectional study was done in 3000 school-going children aged 7–14 years.Materials and Methods:A detailed case history and clinical examination were performed on the entire sample population. TDIs were recorded according to Andreasen's epidemiological classification of TDIs including World Health Organization codes.Statistical Analysis Used:For finding the independent association of the significant variables with outcome, multivariable logistic regression analysis was used.Results:A prevalence of 10.7% was observed in the sample being studied. Dental trauma was significantly (P < 0.05) associated with male gender, and high statistical significance (P < 0.001) was noted with age, participation in sports, lip seal, and overjet. Fall of the child while playing by himself/herself was the most common cause; afternoon and schools were the most common time and place of occurrence of TDIs, respectively. Single tooth enamel fractures in the left maxillary central incisors were most commonly seen. Adhesive restorations were the most frequent form of treatment required.Conclusions:Organizing studies addressing the prevention and treatment needs of TDIs and educational programs aimed toward parents and school teachers are of paramount importance. Furthermore, recognizing the tremendous treatment negligence is extremely critical to adequately analyze indifference of the people toward dental trauma and its consequences.

Healing of transverse root fracture evaluated by using cone beam computed tomography: Case report with 2 years follow-up

A human dental trauma usually occurs in young patients involving an anterior dentition. A horizontal root fracture (HRF) is uncommon, being only 0.5–7.0% of all traumatic dental injuries. A 9-year-old Saudi boy was received trauma on his face causing HRF at both right (#11) and left (#21) maxillary central incisors. The apical third of tooth #11 was fractured, and #21 was lost. Clinical and radiographic examinations investigation were done, and proper management was carried out. The patient was asymptomatic at 2 years follow-up, and the cone beam computed tomography shows good healing of the two fragments that could be done with fibrous tissue.

Delayed replantation of avulsed tooth with 4½ days extraoral time with 18 months follow up

Avulsion or exarticulation is one of the most severe injuries of the tooth, frequently encountered in young children and the maxillary anterior teeth. Immediate transplantation of the avulsed tooth is the suggested treatment that results in a favorable prognosis, although this may not be possible every time. Here, we present a case report of an 8-year-old girl who sustained an avulsion injury of the maxillary left central incisor with 4½ days extraoral time. Treatment guidelines for avulsed immature permanent teeth with prolonged extraoral dry time were followed. Portland cement was used for obturation of the root canal. The clinical and radiographic findings after 18 months revealed minimal inflammatory root resorption and ankylosis of the replanted tooth, whereas clinically, the tooth was asymptomatic and maintained the aesthetics of the child, suggesting the importance of replantation, although there was prolonged extraoral dry time.

Replacement of missing tooth in esthetic zone with implant-supported fixed prosthesis

In the anterior region, the common reason for tooth loss is due to traumatic injury or congenital anomaly. Loss of a single tooth may cause functional and esthetic deficits to the patient. There are different treatment options available for replacing a missing incisor. Implant dentistry should be considered as first treatment alternative for replace a missing tooth. This case report presents the replacement of a missing maxillary left central incisor in a compromised site with dental implants along with bone graft followed by frenectomy to obtain a good clinical result and for better function and esthetics of the patient.

Early treatment of nonsyndromic oligodontia: a clinical case report

This report aims to describe the clinical case of a 10-year-old male patient (R.C.B.C.), presenting nonsyndromic oligodontia with maternal family trait and absence of 22 permanent teeth. Clinically, the patient had prolonged retention of some primary teeth and presence of permanent maxillary left central incisor, permanent mandibular right central incisor and four first permanent molars. Radiographically, only permanent maxillary second molars and mandibular third molars were developing, whereas all other germs of permanent teeth were missing. Treatment consisted of maxillary expansion followed by moving permanent maxillary left central incisor bucco-mesially, and rehabilitation of spaces with removable denture, where the main goal was to restore function and esthetic harmony. The case has been monitored for the past six years. Nonsyndromic oligodontia is a rare condition that poses significant functional and psychosocial difficulties. Treatment usually requires a multidisciplinary approach among which pediatric dentistry and orthodontics play a major role. In view of its complexity, treatment should be initiated as early as possible to minimize future functional and aesthetic issues. Dental implants are considered as definitive treatment of cases of oligodontia, however, until the patient reached the ideal age, other treatments to ensure aesthetics and function must be performed.

CORRELATIVE ANALYSIS OF NAIL FORM TO TOOTH FORM

Aim: This observational study investigated the correlation of nail form to tooth form.Materials and Methods: Measurements of the length and width of left maxillary central incisor and the nail of the left hand’s forefinger of 110 subjects were taken with the help of a calibrated manual vernier caliper. The information obtained was statistically analyzed using Pearson’s correlation test.Results: A positive correlation existed between incisor length and nail length (P = 0.001), and incisor width and nail width (P = 0.001). Consistent relationships were also observed between these measurements.Conclusion: A definite correlation exists between nail form and anterior tooth form. It can be inferred that nail form can be considered amongst other parameters in determining the anterior tooth form.

Orthodontic Treatment of Unilateral Impacted Complete Transposed Maxillary Canine and Impacted Dilacerated Maxillary central incisor

Aims: The purpose of this article was to present a case of surgical exposure and orthodontic reposition of impacted dilacerated maxillary left central incisor. Also surgical exposure of impacted maxillary left canine followed by orthodontic treatment of canine-lateral incisor complete transposition. result : this article describe the treatment of a teenager girl who had impactions of the maxillary left central incisor and canine as well as canine-lateral incisor transposition. The dilacerated impacted central incisor was uncovered and orthodonticaly extruded into the dental arch. Then the impacted canine was surgically exposed and orthodonticaly moving the tooth palately then distally to brought it into its normal position. Conclusion : concurrent impaction and transposition of maxillary anterior teeth is uncommon and poses a challenge for the dentist. Early diagnosis and management of eruption disturbances give us both esthetic and functional outcome benefits.

Spectrophotometric color analysis of maxillary permanent central incisors in a pediatric population: a preliminary study.

Although several studies have reported the color distribution of maxillary central incisors and the effects of age and gender, a reliable database of the color of newly erupted teeth with open apices and the effect of the root development stage on tooth color shades do not currently exist. The purpose of this in vivo study was to perform a spectrophotometric color analysis of maxillary permanent central incisors based on apical developmental stage, age, and gender groups. A total of 734 maxillary permanent central incisors from 367 children aged 7-18 years who have fully erupted, intact, unrestored, vital right and left maxillary central incisors were evaluated. The patients were divided into nine groups, according to the root development stage and age. Digital images were quantified by non-contact spectrophotometry to determine the tooth color. Each tooth's color shade and L*, a*, and b* values were recorded. The L*, a*, and b* values were analyzed statistically with a multivariate analysis of variance test, and the color shades were analyzed with chi-square tests at the α = 0.05 level. The most common general tooth shade, for both genders, was A2. A statistically significant difference was found between the 7- to 12-year-old and 13- to 18-year-old age groups in the general tooth shade and its L* value in the overall, cervical, middle, and incisal sites (P < 0.05). There is a strong relationship between the apical developmental stages of the teeth and the L* values.

Fracture Resistance of Straight and Angulated Zirconia Implant Abutments Supporting Anterior Three-Unit Lithium Disilicate Fixed Dental Prostheses.

The purpose of this study was to evaluate fracture resistance of straight and angulated zirconia implant abutments supporting anterior three-unit lithium disilicate fixed dental prostheses (FDPs). Four different test groups (n = 8) representing anterior three-unit implant-supported all-ceramic FDPs were fabricated to fit an in vitro model with two implants. Groups 1 and 2 simulated a clinical situation with an ideal implant position for maxillary left central and right lateral incisors from a prosthetic point of view, which allowed for the use of a straight, prefabricated zirconia and titanium abutment. Groups 3 and 4 simulated a situation with a compromised implant position that required an angulated (15-degree) abutment. Tapered internal-connection implants (Direct's Legacy, 13-mm length, 3.7-mm diameter, Implant Direct) mounted in epoxy resin models were used in this study. Lithium disilicate (IPS e.max press, Ivoclar Vivadent) three-unit FDPs were fabricated and cemented using self-adhesive resin cement. The samples were subjected to thermocycling (2 × 3,000 × 5°C/55°C) and mechanical loading (TCML; 50 N × 600,000 cycles). Fracture resistances were determined for all the samples that survived aging. Kruskal-Wallis analysis of variance and Mann-Whitney U tests were performed to test for differences in fracture strength values at a 5% significance level. All samples subjected to TCML survived without mechanical failure. The highest fracture loads were associated with FDPs supported by implants with 0-degree abutment angulations compared with those FDPs supported by 15-degree abutment angulations (group 1: 538.7 ± 24.77 N; group 2: 542.17 ± 21.64 N; group 3: 523.57 ± 19.71 N; group 4: 528.37 ± 24.57 N). This difference in load-bearing capacity was not statistically significant (P > .05). The use of angulated zirconia abutments for compensation of nonideal implant locations is possible without reducing the load-bearing capacity of implant-supported anterior three-unit lithium disilicate FDPs.

Mesiodens surgery at deciduous and permanent dentition

Introduction and Objective: To report a rare case of a patient who presented two mesiodens and the treatment performed at two moments. Case report: A 7 year-old male patient reported a supernumerary tooth extracted at age 4. The dental clinical exam revealed giroversion of permanent maxillary right central incisor. Cone-beam computed tomography (CBTC) revealed a presence of a mesiodens located at the buccal surface mesially to the permanent maxillary left central incisor and also indicated that the mesiodens was located close tothe f loor of the nasal cavity. The surgery was performed with a conservative intervention and osteotomy by preserving the adjacent structure. The one-year following-up post-operative x-ray indicated new bone deposition and a more favorable eruption position of the right permanent maxillary lateral incisor. Conclusion: It can be concluded that an early diagnosis by CBTC allowed an adequate treatment planning, which avoid the formation of cysts and a prolonged retention of permanent tooth.

Management of late dental trauma healing complications in primary teeth: a case report of 3 years follow-up

Objective: This case reports the management of late healing complications in primary teeth after dental trauma. Case Report: A 6-year-old girl was referred to the pediatric dentistry clinic with a huge swelling associated with her anterior maxillary left-side region as a main complaint. Her mother reported a traumatic injury in the affected tooth one year before. The clinical exam revealed a noncomplicated fracture and an extensive abscess, both radiographically associated with the left maxillary central incisor. Additionally, pulp obliteration in its homologous tooth was observed. The abscessed tooth was extracted and the homologous tooth was maintained, the child was followed up for three years. No crown or root pathological alterations were observed in either erupted permanent successors. Conclusion: Traumatic injury in the primary teeth may show no initial healing complication however, the follow up and treatment of acute healing complications is essential until the eruption of the permanent tooth.

Aesthetic implant: A new era of aesthetic dentistry

The dental implant is used to replace the natural tooth system. It requires comprehensive preoperative planning and precise surgical execution. In this case report, a 45 year old male presented with missing upper left maxillary central incisor which was extracted 5 months back. He had discomfort during function and unwillingness to smile. He wanted to replace that edentulous area. The treatment options for replacing the missing tooth were discussed with the patient. Finally, with patient's consent the decision was made to replace that edentulous area with an implant supported porcelain fused to metal prosthesis in an esthetic manner. Recall visits exhibited patient's high-level confidence of smile with optimum satisfaction and successful aesthetic outcome.

Genetic and clinical risk factors of root resorption associated with orthodontic treatment.

External apical root resorption (EARR) is a common complication in orthodontic treatment. Despite many studies on EARR, great controversies remain with regard to its risk factors. The objective of this study was to explore the relationship among sex, root movement, IL-1RN single nucleotide polymorphism (SNP) rs419598, IL-6 SNP rs1800796, and EARR associated with orthodontic treatment. Altogether 174 patients (with 174 maxillary left central incisors) were selected for this study. Cone-beam computed tomography was performed before the start of the treatment and at the end of the treatment. Cone-beam computed tomography data were used to reconstruct a 3-dimensional image of each tooth; the volume and the root resorption volume of each tooth were calculated. Three-dimensional matching was used to measure the amount of movement of each root. Genomic DNA was extracted from buccal swabs, and genotypes of SNP rs419598 and SNP rs1800796 of each subject were determined using TaqMan polymerase chain reaction genotyping (Applied Biosystems, Foster City, Calif). The data were analyzed with multiple linear regression analysis. The statistical analysis indicated no relationship between sex, tooth movement amount, and IL-1RN SNP rs419598 with EARR. The IL-6 SNP rs1800796GC was associated with EARR, and root resorption differed significantly between SNP rs1800796GC and CC. IL-6 SNP rs1800796GC is a risk factor for EARR. The amount ofroot movement, IL-1RN SNP rs419598, and sex as risk factors for EARR need further study.

Irritation Fibroma Associated with Ectopic Eruption of the Maxillary Incisor

Irritation fibroma is a common hyperplastic lesion of the oral mucosa that can occur in response to chronic irritation or trauma. This report presents an unusual case of irritation fibroma associated with ectopic eruption of the maxillary left central incisor in a patient with Angelman syndrome. Considering the patient`s medical history and cooperative ability, excisional biopsy under intramuscular sedation using midazolam was performed. The patient exhibited successful healing without lesion recurrence. It is important to perform histopathological examination followed by excisional biopsy, because other benign or malignant tumors may mimic the clinical appearance of an irritation fibroma.

Management of a Previously Treated, Calcified, and Dilacerated Maxillary Lateral Incisor: A Combined Nonsurgical/Surgical Approach Assisted by Cone-beam Computed Tomography

Teeth with calcified canals, dilacerated roots, and associated large periradicular lesions involving both cortical plates pose a challenge to dentists. In addition to the nonsurgical endodontic treatment, such teeth may require surgical intervention with concomitant use of bone grafting materials and barrier techniques. These techniques, when combined with the use of a host modulating agent such as platelet-rich fibrin (PRF), may improve the chances of success. A 26-year-old woman was referred for dental treatment with a recurrence of an intraoral sinus tract 2 months after periradicular surgery in the upper anterior region. Clinical and radiographic examinations revealed a calcified and perforated maxillary left lateral incisor with a severely dilacerated root as well as an associated large radiolucent lesion surrounding the roots of the maxillary left central and lateral incisors. A cone-beam computed tomographic scan of the anterior maxilla showed erosion of the labial and palatal cortical plates in the same region. A calcified canal in the lateral incisor was negotiated up to the straight line portion of the canal. Periradicular surgery with root-end resection was performed, and root-end filling was performed with mineral trioxide aggregate. The perforation present on the middle third of the labial surface of the root was repaired with mineral trioxide aggregate, and the canal was cleaned, shaped, and obturated. A PRF scaffold was prepared and used with a collagen membrane and a freeze-dried bone allograft. Follow-up visits after 3 months, 6 months, and 1 year revealed satisfactory clinical and radiographic healing. The combined use of nonsurgical and surgical modes of treatment cannot be overemphasized in this case. The use of PRF along with a bone graft and a barrier membrane may have enhanced the speed of healing and the resolution of periradicular radiolucency by enhancing bone regeneration.

Esthetic Rehabilitation of Crown Fracture Utilizing Orthodontic Extrusion and Restorative Modality

INTRODUCTION: Complicated crown fractures involve enamel, dentine and the pulp, whereby the most commonly affected tooth is the maxillary central incisor. Fractures of anterior teeth cause not only esthetic and functional, but also psychological problems. Various treatment modalities are available depending upon the clinical, physiological and radiographic status of the involved tooth. In complex cases, a combination of endodontic, periodontal, orthodontic and restorative procedures may be required. CASE DISCUSSION: This case report describes the management of a crown fracture of maxillary left central incisor. A complex procedure was designed to manage this case including orthodontic extrusion to move the fracture line above the alveolar bone and surgical recontouring of the altered gingival margin. Finally, the tooth was restored prosthodontically. Prosthodontic treatment was based on performing post and core and all ceramic crown on the extruded tooth. CONCLUSION: The treatment resulted in good esthetics and secured periodontal health. This case report demonstrates that a multidisciplinary treatment approach is a reliable and predictable option to save a tooth.

Effect of Cast Modification on Linear Dimensional Change of Acrylic Tooth Position Following Maxillary Complete Denture Processing.

To investigate the effect of different cast modifications on the vertical and horizontal tooth position following maxillary complete denture processing. A total of 60 maxillary master casts were prepared and arranged in six groups (n = 10). Variation in modifications between study groups 1 through 6 were as follows: no modification, butterfly post palatal seal preparation only, butterfly post palatal seal preparation with 10 mm wide/4 mm deep box, butterfly post palatal seal preparation with 10 mm wide/4 mm deep box and four round holes, butterfly post palatal seal preparation with 20 mm wide/4 mm deep box, butterfly post dam preparation with 20 mm wide/4 mm deep box and four round holes, respectively. The boxes in the respective groups were prepared on the mid-heel area of the cast. The first group was included in the study as control. The initial master cast was indexed to standardize the measurement technique on all specimens before duplication. Maxillary denture tooth set-up was completed and indexed using laboratory putty to ensure a similar set-up on all specimens. Vertical and horizontal tooth positions were measured for the maxillary left central incisor, right and left first molars in waxed complete dentures, and following processing. The measurements were done using a digital vernier caliper with manufacturing accuracy of up to 0.01 mm. The study data were entered in a Microsoft Excel Spreadsheet. Statistical analysis was done using a paired Student t-test, ANOVA, and Tukey post hoc test set at 5% level of significance. The paired t-test (within groups) showed significant change in all linear tooth positions for groups 1 and 2. Groups 3 through 6 had significant change in vertical dimension only. One-way ANOVA indicated that no significant difference was seen in the vertical tooth movements between the groups; however, statistically significant reduction was seen in the horizontal tooth movements at the maxillary left central incisor, right and left first molars for groups 3 through 6 when compared to others without significant difference between them. Within the limitations of the study, it was concluded that the movement of the teeth horizontally could be reduced with master cast modification (box alone or box and round holes) whereas the vertical movement of the teeth was not affected by the cast modifications made across all groups.

Relationship between maxillary central incisor proportions and facial proportions

Statement of problemNo universally accepted parameter exists for selecting maxillary central incisors (MCIs) relative to facial proportions. PurposeThe purpose of this prospective clinical study was to determine the relationship between MCIs and facial height and width in adults, intersex differences, and measurement differences between right and left MCI. Material and methodsA prospective study was undertaken of 149 dental students (F:76; M:73) aged between 18 and 30 years. Anthropometric MCI and horizontal and vertical facial measurements were recorded with digital calipers by 1 operator. Correlation was investigated with Pearson correlation coefficients (α=.05). Two-sample t tests were used for intersex comparisons and paired t tests to compare right and left MCIs. Intraexaminer reliability was tested by remeasuring 25 participants and applying the Bland-Altman and Lin analyses. ResultsThe mean MCI height was 10.28 mm (right and left) and the mean widths were 8.65 mm (right) and 8.66 mm (left). Intersex incisor differences existed for height measurements (M:F 0.54 mm [right], 0.46 mm [left]) and width measurements (M:F 0.26 mm) but not for width-to-height ratios (F=0.85; M=0.84). A mean ratio of 15.56 was found between bizygomatic width:tooth width (M=15.75, F=15.37) and of 17.93 between total face height:MCI height (M=17.97, F=17.89). Correlation coefficients were low for all tooth:face measurements. Intraexaminer reliability was clinically acceptable. ConclusionsMen had larger teeth and faces but similar width:height ratios. There was no significant size difference between right and left MCI, little individual relationship between tooth:face proportions, and insignificant sex influence. The “biometric ratio”’ of 1:16 for MCI:bizygomatic width was not reconfirmed exactly. A ratio of 1:18 is proposed for MCI height to total face height (Tr-Me’) and 1:12 for face height (N’-Me’).

Impacted Central Incisor with Dilacerated Root-Treat with Ease.

A 12-year-old female patient reported to the Department of Orthodontics of Maulana Azad Institute of Dental Sciences, New Delhi with chief complaint of missing upper front tooth. On clinical examination it was found that maxillary left central incisor (21) was missing [Table/Fig-1]. No significant history of trauma or premature/delayed shedding of primary left central incisor was reported. Panoramic and maxillary occlusal view revealed impacted left central incisor with dilacerated root [Table/Fig-2,3]. Since the contralateral central incisor had erupted fully in the mouth and the root formation of the impacted central incisor was almost complete, it was decided to disimpact the tooth (21). Disimpaction was planned by surgical exposure followed by elastic traction with the help of removable appliance. Since the patient had well aligned upper and lower arches in good occlusion, it was decided to use a modified removable appliance for extrusion of 21. A removable appliance with modified labial bow was fabricated. Labial bow in the anterior region was fabricated with 22 gauge wire and helices were incorporated in the labial bow adjacent to left central incisor region. Retention was provided by the acrylic coverage in the palatal region and by well formed retentive clasps. Surgical exposure of left central incisor was performed by open exposure technique. A bondable button was placed onto the labial surface of exposed left central incisor crown [Table/Fig-4]. Patient was trained to use elastic in triangular fashion to engage button on 21, and two helices of the labial bow, which resulted in an extrusive force of 20 grams for disimpaction of 21[Table/Fig-5] [1]. Patient was advised to change the elastic daily and was reviewed every three weeks. At the end of six months, complete disimpaction of 21 was achieved with the tooth in its optimal alignment into the upper dental arch and in good relation with lower teeth [Table/Fig-6,7]. Post disimpaction panoramic view reveals tooth 21 in the optimal position with respect to maxillary occlusal plane [Table/Fig-8]. [Table/Fig-1]: Pretreatment intraoral maxillary occlusal photograph showing missing maxillary left central incisor. [Table/Fig-2,3]: Pretreatment panoramic and maxillary occlusal view showing vertically impacted maxillary left central Incisor with dilacerated root. [Table/Fig-4]: Intraoral frontal photograph after surgical exposure and with bonded attachment on labial surface of 21. [Table/Fig-5]: Intraoral frontal photograph showing mechanics for extrusion of 21 with elastic traction force. [Table/Fig-6,7]: Post treatment intraoral frontal and maxillary occlusal photographs showing 21 in alignment and good occlusion. [Table/Fig-8]: Post treatment panoramic view. In young patients, absence of maxillary anterior teeth has a major impact on esthetics, phonetics, mastication and psychosocial well being. Impaction of maxillary permanent central incisor due to dilaceration in the root is a rare condition which is associated with trauma to primary anterior tooth early in life leading to dilaceration of permanent succedaneous tooth [2]. Depending on the severity of dilacerations, decision is usually taken to either expose and align the maxillary central incisor or extract and replace it with prosthesis. Although prognosis of disimpaction of dilacerated central incisor is questionable but orthodontic alignment was preferred in this case due to two reasons. Following extraction of a tooth, the alveolar ridge becomes deficient both vertically and labiolingually which makes it unsuitable for prosthetic implant. Also, the region becomes unaesthetic for conventional prosthetic bridge placement. Any fixed prosthesis for replacement of missing central incisor cannot be given before 18 year of age to allow for completion of alveolar bone growth in growing children [3]. The removable appliance treatment chosen for this patient was a convenient treatment option with less chair side involvement with the patient. Moreover it reduces the overall treatment time required for fully bonded fixed appliance therapy since traction could be applied to the impacted tooth immediately after removable appliance insertion. Also, one of the major advantages of using this simple appliance is that it overcomes the detrimental effects encountered with fixed appliances such as demineralization and difficulty in maintenance of oral hygiene [4]. Orthodontic extrusion of an impacted tooth is usually carried out by a trained specialist by using fixed mechanics. A modified removable appliance with bonded attachment and elastic traction has been used to successfully disimpact and align maxillary central incisor in this case. Such an appliance can be fabricated and used by even a general practitioner with basic knowledge about optimal force delivery.