Evaluation of Clinical Effectiveness of Churro Jumper Appliance in the Treatment of Skeletal Class II Malocclusion with Retrognathic Mandible

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1 /jp-journals RESEARCH ARTICLE Sandeep Atmaramji Jethe et al Evaluation of Clinical Effectiveness of Churro Jumper Appliance in the Treatment of Skeletal Class II Malocclusion with Retrognathic Mandible 1 Sandeep Atmaramji Jethe, 2 Ravi Gupta, 3 Jayesh Rahalkar 4 Shivaji Ashok Khedkar, 5 Ketan Mhatre, 6 Charudatta Naik ABSTRACT Introduction: The Churro Jumper is an efficient, inexpensive and uncomplicated fixed flexible functional appliance. Aim: To evaluate the efficacy of the Churro Jumper appliance in treatment of skeletal Class II malocclusion with retrognathic mandible. Materials and methods: Six patients were chosen with skeletal Class II malocclusion randomly with mean age of 11 years to 9 months. Average study period was 4 months. Cephalometric analysis and model analysis were used to measure skeletal and dental changes. Results: Churro Jumper contributes in correction of Class II molar relationship by dentoalveolar effects on both jaws. There was uprighting of maxillary incisors and proclination of mandibular incisors. Conclusion: Churro Jumper is clinically effective as well as efficient appliance in skeletal Class II malocclusion. Keywords: Churro Jumper, Class II malocclusion. How to cite this article: Jethe SA, Gupta R, Rahalkar J, Khedkar SA, Mhatre K, Naik C. Evaluation of Clinical Effectiveness of Churro Jumper Appliance in the Treatment of Skeletal Class II Malocclusion with Retrognathic Mandible. J Ind Orthod Soc 2013;47(2): INTRODUCTION Functional orthopedic treatment seeks to improve skeletal and dental relationship of the jaws. The challenging task is to correctly position jaws anteroposteriorly and vertically with correct overbite, overjet and centric relation. This can be done using myofunctional appliances, which require favorable growth, proper treatment planning and good patient cooperation. A number of fixed functional appliances have gained popularity in recent years to help achieve better results in noncompliance patients. 1 The Churro Jumper 2 is a fixed flexible functional appliance that was introduced by Dr Ricardo Castanon and Dr Larry White in The Churro Jumper provides the orthodontists with 1,4 Reader, 2,3 Professor, 5 Professor and Head, 6 Dean 1,5 Department of Orthodontics and Dentofacial Orthopedics Yashwantrao Chavan Memorial and Rural Development Foundation s Dental College and Hospital, Ahmednagar, Maharashtra, India 2,3,6 Department of Orthodontics and Dentofacial Orthopedics, DY Patil Dental College and Hospital, Pune, Maharashtra, India 4 Department of Oral Medicine and Dentomaxillofacial Radiology, PDU Dental College and Hospital, Solapur, Maharashtra, India Corresponding Author: Shivaji Ashok Khedkar, Reader, Department of Oral Medicine and Dentomaxillofacial Radiology, PDU Dental College and Hospital, Kegoan, Solapur, Maharashtra, India drshiva2001@yahoo.com Received on: 16/12/11 Accepted after Revision: 12/9/12 68 an effective and inexpensive alternative force system for the anteroposterior correction of Class II and III malocclusion. 2 The Churro Jumper 2 appliance therapy resulted in redirection of maxillary growth, mesial tooth movement in the mandible and distal tooth movement in the maxilla. All of which are factors of importance for the transformation of the skeletal Class II malocclusion into neutral occlusion. The primary advantage of any fixed functional appliance is the independence of cooperation from the patient. It has been claimed that; with this appliance, orthopedic effect could be achieved but proof is lacking. The aim of the present investigation was to analyze the effect of the Churro Jumper appliance on the dentofacial complex during the treatment of Class II malocclusion with retrognathic mandible, in growing children and compares the standard cephalometric norm before treatment and after 5 months removal of Churro Jumper. AIMS AND OBJECTIVES The main aim of this study was to evaluate the clinical efficacy of Churro Jumper appliance in the treatment of skeletal Class II malocclusion with retrognathic mandible. Other objectives of current study was to evaluate the changes brought about by the Churro Jumper appliance in horizontal and vertical direction, the soft tissue changes, the amount of overjet and overbite reduction, the correction of molar and canine relationship achieved during the first 5 months of treatment and also the compliance of patient with Churro Jumper appliance. Also, evaluate the validity of the

2 JIOS Evaluation of Clinical Effectiveness of Churro Jumper Appliance in the Treatment of Skeletal Class II Malocclusion Predictive equation given by Susi Caldwell and Paul Cook for the expected percentage reduction in overjet. 3 Predictive Equation is expected percentage of reduction in overjet = (where X1 = pretreatment overbite and X2 = pretreatment SNB. 3 MATERIALS AND METHODS Six cases of skeletal Class II malocclusion with retrognathic mandible were selected. All the patients were in the age group of 11 and 16 years including both male and female. Pretreatment cephalometric analysis was done for each patient and patients with increased angle ANB (4-8 ) and favorable functional analysis with favorable growth pattern were included. Middle phalanx 3 (MP3) radiograph was also used to determine the developmental stage of all subjects, only subjects who were in prepubertal spurts were included in the study. Patients with moderate to severe crowding, patients who had undergone orthodontic treatment in the past were excluded from the study. The subjects that met the above said criteria were treated with fixed preadjusted edgewise appliance therapy. The records collected includes a detailed clinical history, diagnostic casts, middle phalanx radiograph, orthopantogram and lateral cephalogram before the treatment and 4 to 6 months after removal of Churro Jumper appliance and compared with standardized cephalometric norms. Fig. 1: Churro Jumper CONSTRUCTION OF CHURRO JUMPER Wire of inches diameter was used to make a coil of 15 to 20 symmetrical and closely placed circles (Fig. 1). Then a small disposable plastic syringe filled with a mixed polyvinyl impression material that was injected into the lumen of the jumper. This filled the appliance with a material that does not restrict its flexibility, but prevents the coil from opening and pinching the tongue and cheeks during its function. It is important that the ends of the mandibular archwire be annealed and bent down distal to the terminal molars to act as tiebacks that will limit flaring of the mandibular incisors. As the Churro Jumper needs space to slide on the mandibular archwire, the first premolar brackets were omitted. The length of the jumper was determined by the distance from the distal of the mandibular canine bracket to the mesial of the headgear tube on the maxillary molar band, plus 10 to 12 mm (Figs 2A and B). This measurement was transferred to the Churro Jumper, with the coil closer to the canine bracket than to the headgear tube. The maxillary circles were completely closed, but the mandibular circles were only partially closed to allow their placement over the mandibular archwire and subsequent closure. A pin made of annealed 0.036" (20 gauge) stainless steel wire was used to secure the maxillary circle through the distal of the headgear tube. The maxillary pin was pulled mesially through the headgear tube until the jumper had a slight buccal bow in it, and was then bent down (Fig. 3). Initially, the pin Figs 2A and B: (A) Measurement from mesial of maxillary headgear tube to distal of mandibular cuspid bracket, (B) Proper length of Churro Jumper after adding 12 mm to measurement and forming terminal circles Fig. 3: Maxillary pin activated by pulling it forward and turning it down. Pin initially is not cinched tightly to improve patient comfort and allow future activation The Journal of Indian Orthodontic Society, April-June 2013;47(2):

3 Sandeep Atmaramji Jethe et al was not cinched tightly against the tube, which improved patient comfort and allowed space for later adjustments. At subsequent appointments, as the teeth moved and adjusted to the forces of the Churro Jumper, the headgear pin was pulled forward to reactivate it. In the preparation of the case for the Churro Jumper the upper and lower first molars were banded and preadjusted edgewise " slot brackets (MBT) were bonded. The leveling and alignment was achieved using multiple wires from 0.014" NiTi onward and completed with " stainless steel wire. The study was carried out for 5 months period. Appliance was removed to collect records required for the study. Cephalometric Analysis All the subjects were exposed for lateral cephalometric radiograph in standing position on PM 2002EC Proline Planmeca Cephalometric X-ray machine. Kodak 8 10" films were used. The machine settings were standardizing at 68 kvp, 12 mamp for 0.4 seconds with a film focus distance of 5.2 feet. The radiographs were exposed in natural head position, recorded by asking the subject to view in their own eyes by looking into the mirror position on the wall at a distance of 5 feet. All the X-ray films were exposed, developed and fixed under similar conditions to achieve uniformity of results. All tracing were carried out directly on the cephalogram manually by using matt lacquered polyester acetate paper under similar condition by single individual to reduce systematic error of cephalometric measurement. The linear and angular measure- ments were made by using a set-square and protractor with an accuracy of 0.5 mm and 0.5 respectively. To calculate method error for cephalometric tracing, all cephalogram were retraced by the same operator to compute intraexaminer error by using Dahlberg s equation. The error was well within acceptable range for both linear and angular measurements. RESULTS The statistical results obtained from cephalometric analysis are presented in Tables 1 to 6, and cranial base measurements in patients with pretreatment and post- treatment. Saddle angle (N-S-Ar), articular angle (S-Ar-Go), gonial angle (Ar-Go-Gn), articulare-reference plane (mm), condylionreference plane (mm), posterior cranial base length (mm) showed significant results. Anterior cranial base length (mm) did not show significant changes. To evaluate the validity of the Predictive Equation given by Susi Caldwell and Paul Cook for the expected percentage reduction in overjet within 4 months after constant wear of Churro Jumper appliance in Table 7 and clinical efficiency of Churro Jumper appliance in Table 8. DISCUSSION Churro Jumper appliance stimulate overall amount of mandibular growth in appropriate direction and restrict unfavorable maxillary growth. This treatment modality with the concept of pushing mechanics is to deliver positive vectors of force to stimulate the mandibular growth. Few Table 1: Changes in anteroposterior skeletal measurements in patients with pretreatment and post-treatment. While angle SNA showed significant treatment changes, and angle SNB, ANB and angle facial convexity (NA-Pog) showed highly significant treatment changes SNA Pretreatment Post-treatment SNB Pretreatment Post-treatment ANB Pretreatment Post-treatment NA-Pog Pretreatment Post-treatment Table 2: Change in mandibular length measurements in patients with pretreatment and post-treatment. All parameters of mandibular unit length (Co-Gn), mandibular body length (Go-Gn), ramus height (Art-Go), ramus height (Co-Go) and B point to reference plane showed increase treatment effect on mandible Mandibular unit length (Co-Gn) Pretreatment Post-treatment Mandibular body length (Go-Gn) Pretreatment Post-treatment Ramus height (Art-Go) Pretreatment Post-treatment Ramus height (Co-Go) Pretreatment Post-treatment B point to reference plane Pretreatment Post-treatment

4 JIOS Evaluation of Clinical Effectiveness of Churro Jumper Appliance in the Treatment of Skeletal Class II Malocclusion Table 3: Change in maxillary length measurements in patients with pretreatment and post-treatment. Maxillary unit length (Co-ANS) and A point to reference plane showed significant changes Maxillary unit length (Co-ANS) Pretreatment Post-treatment A point to reference plane Pretreatment Post-treatment Table 4: Changes in vertical skeletal measurements in patients with pretreatment and post-treatment. Ant. Fac. Ht. (Na-Me), Post. Fac. Ht. (Se-Go) and mandibular plane angle (SN-GoGn) showed statistically significant changes Ant. Fac. Ht (Na-Me) Pretreatment Post-treatment Post. Fac. Ht. (S-Go) Pretreatment Post-treatment SN-GoGn Pretreatment Post-treatment Table 5: Changes in dental measurements in patients with pretreatment and post-treatment. Upper incisor to SN plane angle, upper incisor to ref. pl. (mm) showed the significant incisor retraction, lower incisor to mandibular plane (Go-Gn), lower incisor to ref. pl. (mm), also showed significant labial movement. Incisor overjet showed significant reduction U1-SN Pretreatment Post-treatment U1-ref. pl Pretreatment Post-treatment L1-GoGn Pretreatment Post-treatment L1-ref. pl Pretreatment Post-treatment Incisor overjet Pretreatment Post-treatment U6-ref.pl Pretreatment Post-treatment U6-Palatal pl Pretreatment Post-treatment L6-ref. pl Pretreatment Post-treatment L6-mand. pl Pretreatment Post-treatment Molar overjet Pretreatment Post-treatment Upper molar to ref. pl. (mm) showed significant distalization of maxillary molar. Upper molar to palatal pl. (mm) showed significantly intrusion of upper molar, lower molar to ref. pl. (mm) showed significant mesial movement of lower molar and signifanctly extrusion of molars authors have reported practical problems with these types of devices, such as increased frequency of breakage 4 and poor oral hygiene. 5 Study comparing the clinical and cephalometric treatment effect of Churro Jumper appliance have not been reported in contemporary literature till date. The concept of natural head position is not new, as it has been studied by various authors. 6,7 Our study employed the subjects looking into their own eye into a mirror. 8,9 The cephalometric analysis used in our study is modified method introduced by Mills and McCulloch 10 gives the clinician an opportunity to evaluate treatment results by relating alternations in sagittal occlusion to skeletal and dental changes in maxilla and mandible; provides stable landmark for superimposition method. Anteroposterior Skeletal Measurement The maxillary angle analogs to SNA showed minimum reduction by means of This shows that Churro Jumper has growth restraining effect on the maxilla. The findings are in agreement with result of Cope et al 11 who attributed this to occipital-pull headgear like forces acting on the maxilla from the Jasper Jumper appliance. Mandibular angle analogs to SNB, indicating forward mandibular jumping showed increase in angle by Results are not in agreement with the findings of Cope et al 11 but are in agreement with studies by Stucki and Ingerval, 4 The Journal of Indian Orthodontic Society, April-June 2013;47(2):

5 Sandeep Atmaramji Jethe et al Table 6: Changes in soft tissue measurements in patients with pretreatment and post-treatment. In post-treatment group showed significant forward movement lower lip and soft tissue pogonion, also showed significant reduction of H-line angle and lip strain Nasolabial angles Pretreatment Post-treatment Nasomental angle Pretreatment Post-treatment Upper lip prominence Pretreatment Post-treatment Lower lip prominence Pretreatment Post-treatment Chin prominence Pretreatment Post-treatment Lip strain Pretreatment Post-treatment H-line angle Pretreatment Post-treatment Merrifield Z angle Pretreatment Post-treatment Soft tissue chin thickness Pretreatment Post-treatment Table 7: Predictive equation given by Susi Caldwell and Paul Cook for the expected percentage reduction in overjet within 4 months after constant wear of Churro Jumper appliance showed highly significant reduction in overjet in post-treatment group Expected % overjet reduction Pretreatment Post-treatment Table 8: Clinical efficiency of Churro Jumper. The clinical investigation showed increase in difficulty in mastication, difficulty in mandibular movement and maintaining oral hygiene. Some patients also showed muscle pain, ulcer but that is not significant. All patients showed highly significantly breakage of appliance Clinical parameters Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Difficulty in mastication Yes Yes Yes Yes Yes Yes Muscle pain No No Yes Yes No No TMJ pain No No No No No No Ulcers No No No Yes No Yes Difficulty in mandibular movements Yes No Yes No Yes Yes Difficulty in maintaining oral hygiene Yes Yes Yes Yes Yes Yes Comfort Yes Yes Yes Yes No No Breakage Yes Yes Yes Yes Yes Yes and Weiland. 12 It seems possible that the forward growth of mandible is due to glenoid fossa remodeling. 13,14 The mean difference of ANB pre- and post-treatment was The mean difference of NA-pog pre- and posttreatment was and is statistically significant. These findings are in agreement with result of Cope et al 11 and Nazan et al. 15 Mandibular Length Measurements The mean difference in the pre- and post-treatment values for: mandibular unit length (Co-Gn) 7.42 mm, mandibular body length (Go-Gn) 5.08 mm, ramus height (Art.-Go) mm, ramus height (Co-Go) 6 mm and B point to reference plane 8.75 mm. All the values were statistically significant. Results are in agreement with Stucki N and Ingervall B, 4 and Weiland FJ, 12 who demonstrated that both dentoalveolar movement and skeletal movement accomplish the Class II correction in Churro Jumper therapy. Maxillary Length Measurements The mean difference in the pre- and post-treatment values for respective measurements were maxillary unit length (Co-SubANS) mm, A point to reference plane mm. The decrease in the SNA angle and the backward relocation of a point A indicated that the appliance also had a skeletal effect on the maxilla. Furthermore, the uprighting on the upper incisors led to a forward relocation of the point A, because of appositional changes at alveolar area. This may camouflage the restrictive effects on the maxilla. The findings of this study are in agreement with results of Cope JB et al 11 and Nazan et al. 15 Vertical Skeletal Measurements Results of the study showed reduced anterior facial height. This is due to extrusion of lower molar and remodeling changes in glenoid fossa that may have reduced the mandibular plane angle. The findings are in agreement with results of Ulgen et 72

6 JIOS Evaluation of Clinical Effectiveness of Churro Jumper Appliance in the Treatment of Skeletal Class II Malocclusion al 16 who stated that the reason for the stability in the vertical dimension was the horizontal growth. Cranial Base Measurements The measurements of cranial base in relation to mandible are significant whereas the actual length of the cranial base in itself has not changed. Dental Measurements Upper Incisor and Molar Measurements The mean position of upper incisors and upper molars were significantly reduced with respect to SN plane and reference plane. This study is in agreement with Herbst 17 and cervical traction. This difference in treatment response is due to maxillary dentition of the Churro Jumper which was tied together as a unit. This indicates that the line of force application of the appliance which is below and behind the unit s center of resistance. This could have resulted in controlled posterior tipping of incisors and molars around their apices. Lower Incisors and Molar Measurements The skeletal and dental contribution together positioned mandibular incisors mesially by a highly significant margin in post-treatment group. These results are in accordance with the findings reported by Weiland, 12 Cope et al, 11 Heining and Goz. 18 This marked protrusion of lower incisors is due to the force vector of the spring acting on the continuous mandibular archwire, where force acting slightly above center of resistance at the level of clinical crown. The mandibular molar mesialization was cumulative effect of both skeletal and dental changes, analyzing change in position of mandibular molar within the mandible. We found that it moved mesially in Churro Jumper. The result are in agreement with Cope et al 11 and Heining and Goz 18 indicating that despite of precautions taken to provide stable anchorage of the dental arches, dentoalveolar changes occurred during the Churro Jumper period, which can be considered as anchorage loss, functional appliances produce dental effect that may mask and inhibit the desired skeletal changes. 19 Incisor and Molar Overjet Mean values of incisor and molar overjet are 3 and 0.5 mm respectively. The incisor overjet is statistically significant whereas the molar overjet is not. Soft Tissue Measurements Lip strains were decreased during the Churro Jumper application because upper incisors were uprighted during the process. The lower lip also moved forward due to change in lower lip position because of significant movement of soft tissue pogonion was found in the Churro Jumper. Our findings are supported by Cope et al 11 and Nazan et al, 15 who stated that Churro Jumper appliance promotes horizontal growth at the pogonion area and the overlying soft tissue reflects that change. Clinical Efficiency Clinical investigation revealed moderate pain in masticatory muscle after insertion of Churro Jumper in 33.3% patients. This is in agreement to the finding of Pancherz. 20 The forceful forward bringing of mandible resulted in disharmony of the position of condyle leading to hyperactivity of the jaw musculature resulting in increased frequency of muscle tenderness. 21 The similar masticatory difficulties were present initially during first observation period with this appliance (100%). This problem may be due to new pattern of mandibular position established by the functional appliances. 5 About 33.3% patients experienced ulceration on the buccal mucosa. This is generally due to open coil spring being too firmly tensioned so that metal cuts into mucosa. 1 One hundred percent of patients with Churro Jumper appliance showed difficulty in oral hygiene maintenance. These findings are similar to those reported by Schwindling FP, 5 who reported that buccal bowing of appliance prevents effective brushing in buccal area. A total of 66.7% patients were comfortable with this appliance but high breakage was noted. The major drawbacks with these appliances are propensity with which fractures can occur both in appliance itself (mainly in areas that have more acute angles) and in support system (mainly in lower arch). Another drawback is the tendency of the patient to chew on the appliance, possibly contributing to breakage. Our results are in accordance with those obtained by Ritto. 1 Predictive equation given by Susi Caldwell and Paul Cook for expected percentage reduction in overjet within 4 months after constant wear of Churro Jumper appliance is valid. Our results are in agreement with (study done by Caldwell and Cook). 3 CONCLUSION Churro Jumper contributes in correction of Class II molar relationship by differential dentoalveolar effects on both jaws. There is a maxillary restraining effect to which the dentoalveolar effect contributes more as compared to skeletal effect. The reduced mandibular plane angle and reduced anterior facial height may be due to glenoid fossa remodeling and increase in the ramus height leading to anticlockwise rotation of the mandible. Churro Jumper is clinically effective as well as efficient appliance to correct the skeletal Class II malocclusion. The only problem with this appliance is its frequent breakage and oral hygiene maintenance causing inconvenience to both the patient as well as the operator. The Journal of Indian Orthodontic Society, April-June 2013;47(2):

7 Sandeep Atmaramji Jethe et al This study describes the short-term effects of Churro Jumper on Class II malocclusions. The results achieved in treated patients are quiet encouraging. Further research will be needed to assess the long-term results and to confirm the present finding. REFERENCES 1. Ritto AK, Ferriera AP. Fixed Functional Appliance-A Classification. Funct Orthod 2000 Spring 17(2):12-30, Ricardo C, Valdes MS, White LW. Clinical use of Churro Jumper. J Clin Orthod 1998;32: Caldwell S, Cook P. Predicting the outcome of twin block functional appliance treatment: A prospective study. Euro J Orthod 1999;21: Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II malocclusion in the young permanent dentition. Eur J Orthod 1998;20(3): Schwindling FP. Jasper Jumper Color Atlas. Edition Schwindling. Germany Solow B, Tallgren A. Head posture and craniofacial morphology. Am J Phys Anthropol 1976;44: Vig SP, et al. Quantitative evaluation of nasal airflow in relation to facial morphology. Am J Orthod 1981;79: Solow, et al. Intra- and interexaminer variability in head posture recorded by dental auxiliaries. Am J Orthod 1982;82: Cooke MS, Wel SH. An improved method for the assessment of the sagittal skeletal pattern and its correlation to previous method. Eur J Orthod 1988;10(2): Mills CM, MeCulloch KJ. Case report: Modified use of the Jasper Jumper appliance in a skeletal class II mixed dentition case requiring palatal expansion. Angle Orthod 1997;67(4): Cope JB, et al. Quantitative evaluation of craniofacial changes with Jasper Jumper therapy. Angle Orthod 1994;64(2): Weiland FJ. Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper. Am J Orthod 1997;112: McNamara JA, Brudon WL Jr. Orthodontic and orthopedic treatment in the mixed dentition. Ann Arbor: Needham Press 1993; McNamara JA Jr, Bryan FA. Long-term mandibular adaptations to protrusive function: An experimental study in macca mulatta. Am J Orthod 1987;92: Kucukkeles N, Ilhan I, Orgun IA. Treatment efficiency in skeletal Class II patients treated with the Jasper Jumper. A Cephalometric Evaluation 2007;77:3: Ulgen M, Gogen H. Effect of cervical headgear therapy on point B in class II, division I cases. Turk Orthodonti Derg 1989 Nov;2(2): McNamara JA. A comparison of the Herbst and Frankel appliances. Am J Orthod 1990;98: Heinig N, Goz G. Clinical application and effects of Forsus spring. The activator mode of action. Am J Orthod 2001;45: Mills JRE. Clinical control of craniofacial growth. A skeptic s viewpoint. In: McNamara JA (Ed). Clinical Alternation of the growing face. Ann Arbor, Mich: Center of Human growth and development, University of Michigan; 1983; Ruf S, Pancherz H. Temporomandibular joint growth adaptation in Herbst treatment: A prospective magnetic resonance imaging and cephalometric roentgenographic study. Eur J Orthod 1998;20(4): Laskin SM. Etiology of pain dysfunction syndrome. J Am Int Assoc 1969;79(53):147. Erratum It has been brought to the notice of the Journal of Indian Orthodontic Society Editorial Team that the article by Hegde T, Dattada H, Jaiswal RK, titled An Avant-garde Indirect Bonding Technique for Lingual Orthodontics using the First Complete Digital TAD (Torque Angulation Device), & BPD (Bracket Positioning Device). J Ind Orthod Soc 2010;44(2):9-16 omitted to cite the most important person Mr Peter D Sheffield, the innovator of the device that is mentioned in the article. After due examination of the matter put forward by the original copyright holder of the figures, Mr Peter Sheffield (who also holds the intellectual property rights for BPD) and response of the primary and corresponding authors, the investigation committee has concluded to state that Mr Peter D Sheffield holds the right to be the first author of the article and, henceforth, this article should be cited as: Sheffield PD, Hegde T, Dattada H, Jaiswal RK. An Avant-garde Indirect Bonding Technique for Lingual Orthodontics using the First Complete Digital TAD (Torque Angulation Device), & BPD (Bracket Positioning Device). J Ind Orthod Soc 2010;44(2):