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PLANAS DIRECT TRACKS IN YOUNG PATIENTS WITH CLASS II MALOCCLUSION

In Brazil, Class II malocclusions affect approximately one-third of chil-dren in the primary dentition period, and approximately two-thirds ofthe adolescent population. According to many authors, this type ofmalocclusion worsens with time, due to facial growth during child-hood, both in terms of quantity and quality, and the facial pattern isestablished at an early age. The application of the Planas DirectTracks concept and technique may represent an interesting tool forthe correction and prevention of Class II malocclusion in an earlytreatment approach, working 24 hours a day, 7 days a week, applyingoral functions and muscle activity to correct the malocclusion. WorldJ Orthod 2005;6:355–368.

Marcos Nadler Gribel, DDS1

Bruno Frazão Gribel, DDS2

Class II malocclusion is a relativelycommon alteration of the stomatog-

nathic system in primary dentition.According to da Silva,1 33.68% of chil-dren in the primary dentition stage inthe Bauru area of the state of SãoPaulo, Brazil, have a Class II malocclu-sion. Commonly, deep overbite,mandibular retrognathism, and Class IImalocclusion at the canine level accom-pany Angle’s designation of molar rela-tionships. These percentages are worsein the late-mixed dentition stage, andare likely associated with a Class II evo-lution from Class I occlusions with aflush terminal plane, as pointed out byvan der Linden et al.2

As stated by Baccetti et al3 in 1997,“…the results of this study indicate thatthe clinical signs of Class II malocclu-

sion are evident in the deciduous denti-tion and persist into the mixed denti-tion.” The interval considered during theBaccetti et al study averaged 2 years 6months ± 9 months in duration, shows aprogressive worsening of the malocclu-sion, with the involvement of the max-illa, which may become prognathic insome individuals.

Another important consideration isthe amount of facial and mandibulargrowth that occurs during childhood(Table 1). According to Nanda,4 “Thepattern of development in each facialform is established at a very early age,even before the eruption of the first per-manent molars and long before the ado-lescent growth spurt.” This may explainwhy the clinician does not see facialpattern changes during adolescence.

1Continuous Education Program inFunctional Orthopedics, UberabaUniversity, Uberaba, MG, andCECOMP, Belo Horizonte, MG,Brazil.

2Private practice of Orthodontics,Belo Horizonte, Brazil.

CORRESPONDENCEMarcos N. Gribel, DDSAv. Carandaí, 161 - 2nd floor30.130-060. Belo Horizonte, MGBrazilE-mail: [email protected]

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Snodell et al5 showed in 1993 that “At6 years of age, the transverse dimensionshad a greater percentage of the adult sizecompleted than the vertical measure-ments for both males and females. All thetransverse measurements were over 80%complete in growth by age 6 years whenusing age 18 years as 100%, with theexception of nasal width for males, whichwas only 75% complete.” Gribel6 appliedthe same methodology to 3 different lon-gitudinal series (Broadbent,7 Bathia andLeighton,8 and Martins et al9), andreported that not only 80% of transversalgrowth is present in a child 6 years of age,but also 80% in the longitudinal aspect,including the cranial base, maxilla, andmandible (Table 1).

It is interesting to see from values inTable 1 (data from Broadbent7) that, at 1year of age, there is more than half(68.3%) of the adult horizontal compo-nent of the maxilla (ANS-PNS) and 61.7%of the adult mandibular diagonal length(Ar-Gn).

The effects of mandibular change ofposture are well established in the litera-ture. In the 1970s, the Petrovic et al10,11

servo-system facial growth theory starteda new era in terms of methodology. Morerecently, Fuentes et al12,13 have shownthat after advancing the mandible with afunctional appliance, not only are thereincreases in the condylar cartilage thick-ness as well as in the number of dividingcells at the mitotic compartment, thereare also impor tant ef fects on geneexpression in the condylar cartilage, fol-lowing the lateral functional shift of themandible. Voudouris et al14–16 and DeGroote17 demonstrated that just asthe growth of the mandible is affected,other areas are also influenced by the

change of the mandibular posture. Newbone formation at the head of thecondyle and mandibular fossa of tempo-ral bone has been observed. Whenrestriction of maxillary growth is added,overall dentofacial orthopedic contribu-tion is approximately 70% and orthodon-tic (dental) contribution is approximately30%. Voudouris14 concluded, “The poten-tial for condylar growth in juvenile nonhu-man primates in the mixed dentition toinduce increased mandibular lengthappears to be great.”

Figures 1 to 6 show an interestingdemonstration of these experimentalfacts in humans. At 6 years of age, a girlhad a bicycle accident and fractured theright condylar head of the mandible.Nearly 3 years later, the oral surgeon rec-ommended an orthopedic evaluation,because the mandible started showing alateral shift and there was facial asym-metry, which can be seen in thepanoramic and lateral radiographs (seeFigs 1 and 2). At this point, the head ofthe mandible showed the “bifid head ofthe mandible” (bifid condyle) aspect.After 2 years 9 months of treatment, witha series of functional appliances, start-ing with a Bimler A1, substituted 6months later with a Simões Network 1,and finally Indirect Simple Planas Trackswith laterally inclined tracks, interestingadaptations were observable, both in thecondyle of the mandible and themandibular fossae of the temporal bone(the cranial base). The posttreatmentradiograph (see Fig 3) shows only 1 con-tour of bilateral structures (orbits, keyridge, great wings of sphenoid, andmandibular borders), suggesting a cor-rection of the asymmetry. Observe thatnot only 2 mandibular heads are presentat the right temporomandibular joint(TMJ) (see Figs 4 to 6), but there are also2 mandibular fossae (1 medial, the otherlateral). Both fossae are at a lowerheight, compared with the left TMJ. Thisindicates that the top of the mandibularfossa of temporal bone had remodeleddownward, toward the 2 heads of themandible.14–16 It seems that these modi-fications at the TMJ level occur not onlyin nonhuman primates, as Ruf andPancherz have shown with TMJ MRIs. 18

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Gribel/Gribel WORLD JOURNAL OF ORTHODONTICS

Table 1 Linear growth measurements(mm) from 1 to 18 years of age

Cranial base Maxilla MandibleAge (N-S) (ANS-PNS) (Ar-Gn)

1 55.0 38.8 71.03 61.1 43.2 81.56 64.7 47.0 90.09 67.2 50.2 97.0

12 69.6 53.0 103.018 72.8 56.8 115.0

Data from Broadbent7 (Gribel6).


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VOLUME 6, NUMBER 4, 2005 Gribel/Gribel

Figures 1 to 6 are from a previously pub-lished case report that demonstratedTMJ plasticity.19 The initial mandibularshift and facial asymmetry were cor-rected by means of modeling new boneand remodeling old structures.

During childhood there is a greatintensity and velocity of facial growth,5,6

and if it is possible to moderate theamount of growth of the mandible andmandibular fossa of the temporalbone,10,11,14–19 then it may be possible tointerfere in, treat, and correct Class IImalocclusions during the primary denti-tion period, in time to affect the facialpattern.4

Fig 1 (above) Pretreatment panoramic radiograph.

Fig 2 (right) Pretreatment lateral radiograph showing 2 mandibular borders.

Fig 3 (left) Lateral radiograph showingbilateral structures superimposed, with-out double contours, even at mandibu-lar lower and posterior borders, demon-strating the correction of mandibularasymmetry, 5 years after functionalappliance removal, without any retainer.

Fig 4 (right) Three-dimensional recon-struction, showing bifid right condyle, 6years after treatment.

Fig 5 (left) Computerized tomograph,coronal view, showing 2 fossae and 2heads of the condyle in the right TMJ,both below left TMJ level, demonstrat-ing remodeling at the right fossa level,after treatment with a series of func-tional appliances.

Fig 6 (right) Magnetic resonanceimage, coronal view, 7 years after treat-ment, corroborates findings shown inFig 5.

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PLANAS DIRECT TRACKSTECHNIQUE

The Planas Direct Tracks (PDT) techniquerepresents an interesting early treatmentapproach to correct and prevent Class IImalocclusion. Patient compliance is atreatment concern when using functionalorthopedics with removable appliances,even though young patients are easier toinfluence and to obtain cooperation fromthan adolescents.20 This concern applieswith any kind of removable gear, such aselastics, headgear, facial mask, etc.Since PDT are “glued” to the teeth, theywork 24 hours a day, 7 days a week.According to Voudouris et al,16 “Fixedfunctional appliances produce consistentand reproducible head of the mandible-fossa changes compared with the incon-sistent results reported in the literaturefor removable functional appliances.”Further investigation may corroboratethese findings with PDT therapy. It hasbeen postulated that these fixed func-tional appliances are more efficientbecause they maintain the change of themandibular posture at all times, includ-ing during mastication. Planas,21

Simões,22 and Hylander23 have demon-strated the important role of masticationin modeling and remodeling of the stom-atognathic system. Occasionally, in somepatients, during some periods of thetreatment, it is necessary to complementPDT action with an appliance or myother-apy to improve tongue, lip, cheek, andfacial muscle activity.

Diagnosis is an essential step in anykind of treatment. Cephalometric analysesare often not available for this stage ofdevelopment. Facial proportions and max-illomandibular relationships are thereforeobtained by facial analysis. Dental castsand direct examination of the patient mayprovide good information in terms of care-ful planning. Planas symptomatologicgnathostatic and calcographic diagnosis iseffective in determining mandibular devia-tion, asymmetries, and underdevelopeddental arches even in young children.21,22

A functional evaluation of the patient’sstomatognathic system, general health(respiratory alterations, postural changes)may help to identify the need for adequate

stimuli. Proper respiration, mastication,swallowing, head and neck posture, andgood oral habits may also affect the deci-sion-making process and the selection ofthe PDT procedure.

Pedro Planas21 developed his tech-nique of direct tracks in the early 1970s.At that time, the tracks were made ofAdaptic. Today, photoactivated (light-cured) composite resins may be easilyattached to the primary dentition. Thereis no specific indication for a particularcomposite resin brand, but it must havesome resistance to allow for occlusalforces during swallowing and mastication.

Placement of PDT involves prophylaxisof the enamel surfaces, followed by etch-ing of the occlusal surfaces. The adhesiveis applied to the conditioned surfaces andthen light cured. Small amounts of resinare then applied over the selected teeth,building an inclined plane to advance themandible during closure of the mouth,swallowing, mastication, and speech. It isimportant to build individualized tracksover each tooth, to allow normal periodon-tal physiology and stimulation. The ClassII direct tracks show, at the beginning, aflat shape over the occlusal surface of theposterior maxillary primary molar, parallelto the occlusal plane. This allows an ini-tial increase of posterior vertical dimen-sion, unlocking the occlusion and, there-fore, providing the mandible with morespace to star t moving laterally andanteroposteriorly. After a short period,approximately 1 month, more resin isadded to the occlusal surfaces of theposterior teeth, and a triangular profileand a prism shape is obtained (Fig 7).The criteria to identify which teeth will beselected to receive the tracks dependsupon diagnosis and treatment planning,and includes vertical dimension, tootheruption, developmental stage of theocclusion and eruption, and adequatestimulation needs. In some mixed-denti-tion patients, it is possible to apply PDT tothe second primary molars. In this situa-tion, first molar eruption will provide anincrease in posterior vertical dimension,both at the occlusal plane and themandibular ramus, depending on thefacial type (see case 2).

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CASE 1

LAG was a girl, 4 years 11 months of age,with a Class II malocclusion, retrognathicmandible, and deep bite. These findingsare discernable both in radiographs andphotographs (Fig 8). Almost all patientswith Class II malocclusions at this agealso have retrognathic mandibles. Figure9 shows the inclined planes of PDT. Thisis a modification of Planas’ original proce-dure.21 The tracks can be made directlyover patient’s teeth or in an indirect way,as described by Brandão.24 The mainobjective is to change the mandibularposture. The tracks act as interferencesin the normal closing path. The Ruffini-like mechanoreceptors—originated fromthe primary neurons of the mesen-cephalic trigeminal nucleus—detect thenew occlusal contacts and command thetrigeminal motor neurons to fire and acti-vate the main protrusive muscle of themandible, the inferior head of the lateralpterygoid muscles. Unless there is rigidfixation of the mandible, the inferior head

of the lateral pterygoid muscles have towork harder to keep and sustain themandible in a more forward position.When teeth contact, muscle spindles alsowil l be stimulated. Whenever themandible moves, TMJ receptors types Iand II, originated from the primary neu-rons of the trigeminal mesencephalicnucleus (as are muscle spindles andRuffini-like mechanoreceptors of the peri-odontal ligament) are stimulated. Allthese stimuli are consequences of themandibular change of posture, and affectthe neuromuscular response of musclesinnervated by trigeminal, facial, glos-sopharyngeal, vagus, hypoglossal, acces-sory, and cervical nerves (C1, C2, C3, andC4); this effect normally happens duringswallowing and mastication. All thesemovements result in incremental bloodflow increase at the TMJ. Growth factorsarrive at the condylar cartilage and proba-bly exert influence in the number ofmitotic cells and thickness of the condy-lar cartilage, as has been observed inadult animals.25 The movement at the

Fig 7 (a) Lateral view of Planas DirectTracks (PDT) on the mandibular molar(triangular profile). (b) Frontal view ofPDT on mandibular molar (prismshape). (c) Occlusal view of PDT onmandibular molar (prism shape). (d)Frontal view of PDT on maxillary molar(prism shape). (e) Lateral view of PDTon maxillary molar (triangular profile).

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Fig 8 Case 1. Retrognathic mandible, Class II molar and canine relationships, deep bite, “gummy” smile.

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TMJ may produce a “pump-l ikeeffect”.10,13,14–17 This theoretical model isin accordance with the Petrovic et al10

servo-system theory and the modusoperandi of functional appliancesdescribed by Simoes, Petrovic, and Stutz-mann in 1992.26

The hypothesis of lateral pterygoidmuscle inferior head hyperactivity isprobably valid only for those proceduresthat stimulate mandibular advancementin an active way (such as Planas Directand Indirect Tracks, Simões Network 1,MARA, twin block), rather than for thosethat keep and sustain the mandible in aforward position in a passive manner,such as achieved with rigid activators (ie,Bionator, Harvold-Woodside, Fränkel,Bimler, Herbst and its variations). Thismay explain why some authors haveencountered a decrease in pterygoidactivity when using activator-like func-tional appliances instead of an increasein its activity.

After Class II PDT are applied to theprimary first molars, one normally willsee a lateral open bite in Class II deepbite patients in the primary dentition (seeFig 9). This will be corrected within a fewmonths by facial growth and tooth erup-tion. The continuous tooth eruption in pri-mates and the 5 stages of eruption arewell explained in the literature by manyauthors.27 Tooth eruption is a naturalphenomenon that should be taken intoconsideration during treatment planning.

The clinician does not have to pull orpush teeth to make things happen; mostof the time, the clinician must only permit or stimulate things to occur. Asproposed by Planas, in his Laws ofDevelopment, the stimulation of 1 toothproduces the eruption of the teeth thatbelong to the same group: there are 2 groups in the mandible (each hemi-arch) and 3 groups in the maxi l la (1 anterior group, the maxillary incisors;and 2 posterior groups, including thecanines, premolars, and molars fromeach side). This is probably related tothe dif ferent embryologic origins ofthese components.

After 6 months, the mandibular retrog-nathism and the lateral open bite haveresolved, due to teeth eruption (Fig 10).The Class II malocclusion and anteriordeep bite also have been corrected. TheClass II PDT were kept in place for anadditional 2 months to ensure the stabi-lization of all aspects involved (func-tional, neuromuscular, articular, skeletal,dentoalveolar, etc). After that, they wereprogressively removed by gently grindingthe resin. This procedure will allow pri-mary first molars to erupt to the occlusalplane level. Figure 10 shows normaliza-tion of occlusion and of facial propor-tions, both in soft and hard tissues, after6 months. The 9-month follow-up viewssuggest normal development of theocclusion, including a reduction of the“gummy” smile (Fig 11).

Fig 9 Occlusal views of PDT, placedon primary first molars (maxillary andmandibular).


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Fig 10 Case 1. After 6 months, the malocclusion is corrected, allowing normaldevelopment of the stomatognathic system. Lip exercises are often required tostimulate proper lip posture and to discourage mouth breathing.

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Fig 11 Case 1. Views at 9 months posttreatment, showing normal developmentof the occlusion. Lip exercises may still be necessary.

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CASE 2

This girl, JKA, 6 years of age, had a maloc-clusion similar to that of case 1, with aClass II malocclusion, deep bite, retrog-nathic mandible, and some “gummy”smile (Fig 12). However, her first molarswere already erupting. In such a case, theprimary second molar is selected toreceive Class II PDT. Seven months later,the malocclusion was corrected in all 3planes. Note that in the initial views, thepatient showed an inverted curve of Speein the maxilla. In cases like this, it is wiseto supplement the Class II PDT action witha functional appliance for night-time useand, if possible, a few hours each day. Ifchildren are undergoing language training,use of the appliance during the school dayis not recommended. An Equiplan, devel-oped also by Pedro Planas, may stimulateposterior teeth to erupt, and control theeruption of maxillary and/or mandibularincisors, depending upon the placementof this stainless steel plate. The Equiplanmay help to control and reduce a“gummy” smile during this stage of devel-opment. Figure 13 shows the evolution ofthe treatment (total active treatment time,7 months). For the following 7 months, theappliance was used only at night, as aretainer; during this time, the Class II PDTwere ground to allow the primary secondmolars to erupt. Figure 14 shows the nor-mal development of the occlusion 24months posttreatment.

Periodic follow-up visits will proceedthroughout adolescence and youngadulthood. This periodic observation, 2to 4 times a year, assures the possibilityof intervention if anything deviates from“normal” development, including detec-tion or control of any sort of deleterioushabits, altered functions, or disturbancesin tooth eruption. In addition, this is apowerful public relations tool, since par-ents will mention the care of their child’sdental and oral health.

DISCUSSION

With very early treatment, a secondphase of treatment may not be neces-sary.28 There is a good chance for nor-

mal development, if normal form andfunction are obtained early. The sameapproach is valid for any kind of preven-tive procedure: the inoculation of a vac-cine does not mean 100% protection;periodic visits to a dentist cannot guar-antee that a patient will not developcaries. However, if a patient, parents,and clinician adopt prevention in a seri-ous manner, by watching over nutrition,breathing, etc, not only the occlusion, butthe face and general health may beimproved, thus avoiding or minimizinglater interventions.

We can treat malocclusions at almostany age at the beginning of the third mil-lennium. The same is true for caries: wecan prevent caries with educational atti-tudes and supervision; remove cariouslesions when super f icial (enamelinvolved); remove them with some anes-thesia (dentin involved); do endodontictreatment if the pulp is involved; orextract the tooth. In any case, the dis-ease is treated and the patient is cured.Are malocclusions the only health prob-lem that one should observe gettingworse and then interfere?

Even the best orthodontists in theworld have altered their approach duringthe course of their careers. Charles Tweed,often called the world’s greatest orthodon-tist, produced outstanding results with full-banded appliances in the permanent den-tition. But toward the end of his career, hestressed that mixed-dentition therapy wasvital, and he accepted only mixed-denti-tion cases in his practice. Tweed wrote,“As we learn more about growth and itspotentials, more about influences of func-tion on the developing denture, and moreabout normal mesiodistal position of thedenture in its relation to basal jawbonesand head structures, we will acquire a bet-ter understanding of when and how tointervene in the guidance of growthprocesses so that Nature may betterapproximate her growth plan for the indi-vidual patient. In other words, knowledgewill gradually replace harsh mechanics,and in the not-too-distant future the vastmajority of orthodontic treatment will becarried out during the mixed dentitionperiod of growth and development andprior to the difficult age of adolescence.”29

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Fig 12 Case 2. Pretreatment views showing retrognathic mandible, Class II molar and canine relationships, deep bite, andinverted curve of Spee in the maxilla.

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Fig 13 Case 2. After 7 months, the malocclusion is corrected, allowing normal development of the stomatognathic system.Note eruption of first permanent molars and leveling of the occlusal plane.

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We surely know much more today30

than 40 years ago. Why don’t we take astep further?

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3. Baccetti T, Franchi L, McNamara JA Jr, Tollaro I.Early dentofacial features of Class II malocclu-sion: A longitudinal study from the deciduousthrough the mixed dentition. Am J OrthodDentofacial Orthop 1997;111:502–509.

4. Nanda RS. Patterns of vertical growth in theface. Am J Orthod Dentofacial Orthop 1988;93:103–116.

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10. Petrovic AG, Stutzmann JJ, Oudet CL. Controlprocesses in the postnatal growth of the condy-lar cartilage in the mandible. In: McNamara JA Jr(ed). Determinants of Mandibular Form andGrowth. Monograph 5, Craniofacial GrowthSeries. Ann Arbor: Center for Human Growth andDevelopment, University of Michigan, 1975.

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Fig 14 Case 2. Note eruption of second primary molars, 6 months after PDT removal.

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12. Fuentes MA, Opperman LA, Buschang P,Bellinger LL, Carlson DS, Hinton RJ. Lateralfunctional shift of the mandible: Part I. Effectson condylar cartilage thickness and prolifera-tion. Am J Orthod Dentofacial Orthop 2003;123:153–159.

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16. Voudouris JC, Woodside DG, Altuna G, KuftinecMM, Angelopoulos G, Bourque PJ. Head of themandible-fossa modifications and muscleinteractions during Herbst treatment, Part 2.Results and conclusions. Am J Orthod Dentofa-cial Orthop 2003;124:13–29.

17. DeGroote CW. Alterability of Mandibular Condy-lar Growth in the Young Rat and Its Implica-tions [thesis)]. Louvain, Belgium: KatholiekeUniversiteit Leuven Faculteit der Genees-kunde, 1984.

18. Ruf S, Pancherz H. Temporomandibular jointremodeling in adolescents and young adultsduring Herbst treatment: A prospective longitu-dinal magnetic resonance imaging andcephalometric radiographic investigation. Am JOrthod Dentofacial Orthop1999;115:607–618.

19. Gribel MN. É possível tratar-se exclusivamentecom Ortopedia Funcional dos Maxilares? In:Sakai E (ed). Ortodontia Ortopedia Funcional, ed1. São Paulo: Ed Artes Médicas, 2002:245–262.

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21. Planas PC. In: Rehabiltación neuro-oclusal(RNO), ed 1. Barcelona: Salvat, 1987.

22. Simoes WA. Mastigação e Desenvolvimento.In: Ortopedia Funcional dos Maxilares, atravésda Reabilitação Neuro-oclusal, ed 3. SãoPaulo: Artes Médicas, 2003:91–117.

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24. Brandão MRC. Método indireto Brandão: Pis-tas diretas Planas confeccionadas através dematrizes de polipropileno. In: Ortopedia Fun-cional dos Maxilares, através da ReabilitaçãoNeuro-oclusal, ed 3. São Paulo: Artes Médicas,298–313.

25. Mussa R, Mark H, Enlow D, Goldberg J. Condy-lar cartilage response to continuous passivemotion in adult guinea pigs: A pilot study. Am JOrthod Dentofacial Orthop1999;115:360–367.

26. Simoes WA, Petrovic AG, Stutzmann J. Modusoperandi of Planas’ appliance. J Clin PediatrDent 1992;16:79–85.

27. Lee CF, Proffit WR. Daily rhythm of tooth erup-tion. Am J Orthod Dentofacial Orthop 1995;107:38–47.

28. Hamilton DC. The emancipation of dentofacialorthopedics. Am J Orthod Dentofacial Orthop1998;113:7–10.

29. Graber TM. Foreword. Am J Orthod DentofacialOrthop 1998;113:1–4

30. Gribel MN. Planas Direct Tracks in the earlytreatment of unilateral crossbite with mandibu-lar postural deviation. Why worry so soon?World J Orthod 2002;3:239–249.

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