бы appleы х нfi йтхыкы, за шы зхт зт тсыхн, Bayerische Julius- Maximilians UniversitДt, WЭrzburg, бзл с. 2

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1 appleтн ы шы шк шбсрс лб шанобхшх н с л о мк лб шс шлfi тзт тсыхн бз appleб н х абсбхтappleо шыхн : с йтз т appleбзхappleыршб с сшы сы ст з к, 1 сск ко бз к, 2 лappleзт тот лк, 3 хоо ы ок, 4 хнfiо т з к 5 1 бы appleы х нfi йтхыкы, за шы зхт зт тсыхн, Bayerische Julius- Maximilians UniversitДt, WЭrzburg, бзл с. 2 appleхшыклтсхнfi сбза ык, за шы зхт ытл ыхн н х с тappleзтш appleхн цбхзтзахн, л л тсых ызхн, зхшыты обхт сбappleхшы - лхт ёбшш отс нк. 3 apple нтзт какы, за шы зхт ытл ыхн н х с тappleзтш appleхн цбхзтзахн, л л тсых ызхн, зхшыты обхт сбappleхшы лхт ёбшш отс нк. 4 зт тсыхнfi. 5 какы, за шы зхт ытл ыхн н х с тappleзтш appleхн цбхзтзахн, л л тсых ызхн, зхшыты обхт сбappleхшы лхт ёбшш отс - нк. Management of patients with Class II malocclusion treated with combined orthodontic treatment and genioplasty: Report of two cases Konstantinos Lazarides, 1 Ioannis Tilaverides, 2 Lambros Zouloumis, 3 Achilleas Davelis, 4 Nikolaos Lazarides 5 1 Postgraduate student, Department of Orthodontics, Bayerische Julius-Maximilians UniversitДt, WЭrzburg, Germany. 2 Research Associate, Department of Oral and Maxillofacial Surgery, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece. 3 Assistant Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece. 4 Orthodontist. 5 Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece. EPI HФH сыхлбырappleхшк шбсрс лб х ы з ык ш анобхшк appleт с нтс шыкс мк бappleхыа сбы х б ыб лб тзт тсыхн, б ыб лб бхзтзахн бз appleб б ыб ы от лб шс шлfi ы с т ырс бз appleбыхнрс лбfi с. х ыкс бappleхота ык н ы оокоfiыбзк бз appleбыхн сыхлбырappleхшк appleз appleбх с о л сбы х apple' fi хс, бныfi applefi ы нохсхн шытх б н х бз л ы н х к appleзты лкшк н р бapple шк н х тх appleзтш тн б ыт шбс. ыкс бза ш ы с йбзfiл шыб шб т appleбзхappleыршбх шбсрс лб тзт тсыхн с л о мк appleт сыхлбы apple шкн с з хн лб тзт тсыхн бз appleб лб ыкс тappleт appleтн ы шы к- нб лбс к т тсыхн ш анобхшк, оо к шнбобыхн ш злтс apple з лбхсб сбappleкз шык. х ык хfiз шк ык хшкыхн блй - схшк ыт appleзтшрappleт appleз ал ытappleтх кнб мкыхн абсбхтappleо - шыхн лб ытappleт ыкшк ыт оотappleо шыхнт блйыбл ыхнт ох- нт Proplast ( тоыбыз йтзт хо схт). т хшкыхнfi appleт- ы обшл apple змб хн стappleтхкыхнfi н х apple з лбхсб лбы окыт шыт зтсхнfi х шыкл ы с 2 бырс ык лбыба бхзкыхн apple з нт- от кшк. ABSTRACT Treatment of patients with Class II malocclusion includes orthodontics, surgery or a combination of these therapeutic modalities. Patient wishes and expectations should be considered besides clinical findings, for selecting the most appropriate treatment strategy. Two cases of patients with Class II malocclusion are reported in this paper. Both were initially managed with orthodontic treatment that restored dental occlusion, whereas the skeletal discrepancy was not affected. Augmentation genioplasty was performed for facial esthetic correction using the alloplastic implant material Proplast (Polytetrafluoroethylene). The esthetic result was satisfactory and remained stable during the 2-year postoperative follow-up. KEY WORDS: Class II malocclusion, orthodontic treatment, genioplasty Hell Orthod Rev 2004;7: Received: Accepted: E HNIKH E IёEЬPH H 2004 Я TOMO HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

2 : анобхшх н с л о мк, тзт тсых- н бз appleб, абсбхтappleо шыхн оо зт appleх 2004;7: збо йк: ахсб бны : EI A Ь H мк appleтыбоб ыкс appleзрык шб ш сfiыкы х ы з ык ш анобхшк (Kolokithas н х шс., 1989, 1990, 1991, 1992). х шбсб ык н ыкатз ы блй с тс с бз й шл хшкыхнрс н х шанобх- шх нрс х ы з рс тх тappleт б а стсы х б нто сыхокappleы applefi ыкс с ошк н х ык лбо ык ы с нбй отлбызхнрс ныхстаз йхрс (Epker, 1983). applefi знбы бappleх клхт- отахн лбо ыб appleзтн appleыбх fiых 15-20% ы с бй с apple зтшх тс тзхfiсых appleзfiы мк лба о ыбзк шк лб 6 mm. т абатсfi ыfi appleт корсбх fiых с шы ыхшыхн шкл сыхнfi ыл л ыт appleокшлт apple зтшх бх х ы з - шыт л абт шык шк ык ас т (Kolokithas н х шс., 1992; Proffit н х Field, 1993; Proffit, 2000). х шкл сыхнfiыбзтх оfiатх appleт с ан тс ыт шб- сб ыт с с кы штс бз appleбыхн сыхлбырappleхшк ык шанобхшх н ыт с л о б с х нз к хшкыхн блй схшк ы с тсыхрс н х ыт appleзтшрappleт, к х ы з ык л шкыхн обхытза н х шб тзхшл сб appleбзхappleыршбх к apple оо а applefi ы бст окыхн шлappleырл ы шобхытза ык нзты йтас хн х зз шк ( ) (Thomas, 1995; Tucker, 1995). appleхappleо тс к сых- лбырappleхшк ыт appleзт о л ыт бх ш с appleты обшл ык х - ы зкшк ы с тсыхрс шыт йз алfi ах лба о ыбзт зтсх- нfi х шыкл н р к apple змк х ы з рс ык ш анобх- шк бappleхыб сбх ы appleбзхт тсыхн appleзт о л ы appleт шс шсapple з тс шых appleбзхappleыршбх ы (Tucker, 1995). х ыкс сыхлбырappleхшк ы с шбсрс ырс apple з тс х - шхлб 4 х йтзбыхн бappleхота appleт б с х тх бм : 1) зтappleтappleт кшк ык мкшк (growth modification) ык н ы ас т лб з шк обхытзахнрс шшнбрс ршыб с лбызх шб к ш с ота лбы м ы с т ас с. х бсfiкыт оfiат к л т т лappleтзб с бй злтшыб appleтыбобшл ыхнfiыбз шб appleзтбйк х- нт шбсб н р шб ы ыкс кохн к мкшк ы с тшырс ы с ас с б с х сытск. ныбс тзт- тсыхн бз appleб лб з шк apple ах с тзт тсыхнрс шшнбрс лappleтзб с нтот шбх ах ыкс тотно - з шк ык бз appleб (Nelson, 1993). 2) хfiз шк ык с л о лfiст лб тзт тсыхн бз appleб, к тappleт шс шы ы х шб омк ы с с ытл - с appleзт ы apple ш н х лбы н скшк ы с н ы ытл с appleзт ы блappleзfi (compensation of the dentition) ршыб с хтз б к тзхfiсых appleзfiы мк. зfiнбхы х ко ах лх appleзтшapple бх шан о к ыт apple з- тсыт appleзт о л ыт, ах ыfi н х к л т т с - й збы х н х ш с тзт тсыхнfi н лтйо 106 INTRODUCTION Class II constitutes the most frequent malocclusion (Kolokithas et al., 1989, 1990, 1991, 1992). Class II patients present a broad range of esthetic and occlusal disorders that are easily analyzed and studied in cephalometric radiographs (Epker, 1983). Several epidemiological studies show that 15-20% of adolescents present an overjet exceeding or equal to 6 mm. This fact suggests that a statistically significant portion of the population presents a disturbance of mandibular size or position (Kolokithas et al., 1992; Proffit and Field, 1993; Proffit, 2000). Chief complaints of these patients for seeking treatment are mainly esthetic appearance of their teeth and face, disturbed masticatory function and, in some cases, discomforting symptoms of temporomandibular dysfunction (Thomas, 1995; Tucker, 1995). Moreover, Class II orthodontic treatment preserves teeth in the dental arches much longer, since the presence of malocclusion exacerbates periodontal problems that usually coexist in these conditions (Tucker, 1995). Treatment of Class II patients includes 4 different therapeutic modalities: 1) Mandibular growth modification with functional appliances to reduce jaw discrepancies. For obvious reasons, this method may be applied more efficiently in preadolescent patients, since osseous jaw growth at this age is intense. Comprehensive orthodontic treatment with fixed appliances may follow for treatment completion (Nelson, 1993). 2) Malocclusion correction with orthodontic treatment only, including upper incisor retraction and lower incisor protraction (compensation of the dentition) to reduce overjet. It actually constitutes an attempt to camouflage the existing problem; this is why this method is also referred to as orthodontic camouflage. 3) The third alternative is major surgical correction, comprising mandibular advancement performed with sagittal split osteotomy; prior to surgery, occlusal relationships are orthodontically deteriorated (dental decompensation) so that optimal skeletal and dental relationships are achieved postsurgically (Fig. 1). 4) Finally, another alternative includes a combination of orthodontic camouflage and augmentation genioplasty (minor surgery). Genioplasty is considered an operation of minor severity, especially when alloplastic implant materials are used for augmentation of the symphysis (Fig. 2,3) (Proffit and Turvey, 1983; Proffit, 2000). Two cases with Class II malocclusion are presented in this study; they were both treated according to the fourth therapeutic alternative that included orthodontic treatment with camouflage followed by augmentation E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

3 a b хнfiс 1. (a) анобхшх н с л о мк II лб т тсыхнfi шл х шлfi (dental compensation), т тappleт т appleбхнтс бы х лб бхохн applefiнохшк ы с н ы ытл с н х ао шшхн ы с с. (b) бы applefi тзт тсыхн шнfiappleхлк бappleх б с шк ыт appleзт о л - ыт (decompensation). (c) бы applefi бхзтзахн хfiз шк лб т бох appleзт кыхн тшыбтытл. Figure 1. (a) Class II malocclusion with dental compensation revealed with proclination of the lower incisors and retroclination of the upper incisors. (b) Dental decompensation after orthodontic treatment. (c) After surgical correction with mandibular advancement using sagittal split osteotomy. c (orthodontic camouflage). 3) з ык бappleхота б с х к лб с бхзтзахн хб ык- шк, к тappleт шс шы ы х шб appleзтркшк ыт шрл ыт ык н ы ас т appleзт ы блappleзfi (mandibular advancement) appleт бappleхыа сбы х лб т бох тшыб- тытл йт appleзткакб тзт тсыхн бappleх б с шк ы с шанобхшх нрс ш шб с (dental decompesation) ршыб лбы ык бхзтзахн бapple л шк с бappleхыб б к н о ыбзб с ы шнбобыхн н х т тсыхн ш шбх (хн. 1). 4) от, к ы ы зык о шк appleбзхо л сбх шс шлfi тзт тсыхн хб ыкшк ык ш анобхшк (тзт- тсыхнfi н лтйо ) лб мкыхн абсбхтappleо шыхн (бо шш с бapple л шк). абсбхтappleо шыхн б зб ы х шштст з ыкы бapple л шк бх хнfiыбз fiы с ах ыкс мкшк ык appleзтapple ыбх ыт абсб т зкшхлтappleтх- кт с оотappleо шыхн блйыбл ыхн охн (хн. 2, 3) (Proffit н х Turvey, 1983; Proffit, 2000). ыкс бза ш л apple зтшх тсы х т appleбзхappleыршбх шбсрс лб шанобхшх н с л о мк appleт сых- лбы apple шкн с лб ыкс ыбобы о шк, ко з хн лб genioplasty with alloplastic implant material for facial esthetic improvement. A literature review is presented and the criteria for applying each of the therapeutic modalities mentioned above are also discussed. CASE PRESENTATIONS* Case 1 A 15-year old female patient visited the orthodontist seeking treatment of her malocclusion. She presented mandibular deficiency with characteristic bird-like face. The molars were in Angle Class II occlusion, whereas cephalometric analysis revealed a Class II, division 1 malocclusion with severe mandibular micrognathia due to short rami indicating severe skeletal Class II. Medical history did not include any trauma during or *Patient files of both cases were taken from the archives of Prof. N. Lazarides. 107 E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

4 a b хнfiс 2. (a) анобхшх н с л о мк II лб т тсыхнfi шл х шлfi (dental compensation), т тappleт т appleбхнтс бы х лб бхохн applefiнохшк ы с н ы ытл с н х ао шшхн ы с с. (b) зт тсыхнfi н лтйо. (c) бсбхтappleо шыхн лб appleзтш нк оотappleо шыхнт блйыбл ыхнт охнт. c Figure 2. (a) Class II malocclusion with dental compensation revealed with proclination of the lower incisors and retroclination of the upper incisors. (b) Orthodontic camouflage. (c) Augmentation genioplasty with alloplastic material. тзт тсыхн бз appleб (тзт тсыхнfi н лтйо ) н х шык шс бх ах ыкс боы шк ык хшкыхн блй схшк ыт appleзтшрappleт appleз ал ытappleтх кнб мкыхн абсбхтappleо - шыхн лб оотappleо шыхнfi блйыбл ыхнfi охнfi. з оок- о appleз ал ытappleтхб ы х с шнfiappleкшк ык х охтаз й н х шкыт сы х тх appleзт appleт шбх applefi ых тappleт б бй з- лfiбы х к н б бз appleбыхн л т т сыхлбырappleхшк. APOY IA H TЬN EPI TЬ EЬN* 1к appleбз appleы шк шбс кохн 15 бырс бappleхшн йкнб ытс тзт тсых- нfi ах сыхлбырappleхшк х ы з ык ш анобхшк. шбс apple зтш б appleтappleо ш ык н ы ас т лб з ныкзхшыхн бхнfiс appleыкстлтзй. бы applefi лбо - *Oх appleбзхappleыршбх appleзт з тсы х applefi ыт з б т ыт K какы N. - з к. after delivery. Clinical examination of the temporomandibular joint revealed clinical signs of dysfunction, such as pain upon pressure in the area, noises and mandibular deviation during mouth opening. Following analysis of clinical and radiological findings, the orthodontist proposed major surgical correction with combined orthognathic surgery and orthodontic treatment. However, the patient was reluctant to undergo major surgery and preferred the solution of orthodontic camouflage disregarding the esthetic problem that would not be corrected. The malocclusion and functional problems were managed with orthodontic treatment (camouflage) (Fig. 4a). Nevertheless, since the skeletal discrepancy was not corrected, the esthetic problem persisted. Following reevaluation when the patient was 19 years old, it was decided to improve the patient s face with a surgical procedure of minor severity, such as E HNIKH E IёEЬPH H 2004 Я TOMO HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

5 a b c d хнfiс 3. кл ыхн apple з шы шк ы с х т хнрс шы с бс тшытл ыхн ытappleт ыкшк оотappleо шыхнт блйыбл ыхнт охнт ах ыкс мкшк ыт абсб т. (a) с тшытл ыхн ытл. (b) appleтн о к ык абсбх н appleбзхт. (c) тappleт ыкшк ыт охнт. (d) зз - й шб т шызрл ы. Figure 3. Schematic presentation of stages involving intraoral placement of alloplastic implant material for chin augmentation. (a) Intraoral incision. (b) Surgical exposure of symphysis. (c) Material placement. (d) Suturing in two layers. ык ы с бнл аб с х appleхшыркнб fiых тх атлй тх б с ш анобхшк мк н ы ngle, бср к нбй отлбызхн с ошк бхмб fiых бappleзfiнбхыт ах шанобхшх н с л - о мк н ыкатз 1. apple шк applefi ыкс нбй отлб- ызхн с ошк х appleхшыркнб сытск лхнзтас ык н ы ас т, лб нтсыт но т абатсfi appleт шсыб- от шб шыкс клхтза ык шнбобыхн мк. applefi ыт хшытзхнfi бс с й зкнб appleзткат лбск н н - шк н ы ык х знбх лбы ытс ытнбыfi. applefi ыкс нохсхн бм ы шк ык нзты йтас хн х зз шк х appleхшыркнб к apple змк шобхытзахнрс шклб с, fiapple applefiст н ы ыкс apple бшк ык appleбзхт, нзfiытх н ы ык х стхмк ыт шыfiл ыт н х apple з ннохшк ык н ы ас т н ы ык 109 augmentation genioplasty using Proplast (Vitek, Inc., Dallas, Texas) (Fig. 4b,c,d,e). Surgery was performed under general anesthesia and postoperative patient condition was normal. The esthetic result immediately after surgery was satisfactory and it remained stable during the two-year follow-up (Fig. 4f,g). Case 2 A 22-year old female patient with mandibular micrognathia visited the orthodontist for correction of the esthetic problem involving chin hypoplasia (Fig. 5a). The evaluation of dental casts and radiographs revealed a Class II, division 1 malocclusion similar to E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

6 a b C d e f хнfiс 4. (a) хб ыкшк ык т тсыхн ш анобхшк лб тзт тсыхнfi н лтйо. (b) цбхзтзахн appleтн о к ыт абсб т. (c) тнхл ыт Proplast шык нызх appleбзхт. (d) зтбытхл ш ыт Proplast шб х ол сых хтыхнт. appleбх ыт Proplast б с х appleтзр б охнfi мбappleо сбы х лб йшхтотахнfi тзfi н х ытappleтбыб ы х шб ш зхаа 50 ml appleт appleбзх бх 1 gr нбй отшappleтз ск х ол ск шб йшхтотах- нfi тзfi. б н ы оокот бхзхшлfi клхтзат лб нбсfi зт шык ш зхаа ршыб с appleтл нзсб т з appleт apple з бх бано х- шл ст шыт applefiзт ыт охнт н х с бхш обх ыт сых хтыхнfi л ш шб ыт. (e) т Proplast ытappleтбыб ы х шыкс н ы оок- ок шк ыт абсб т н х нхскытappleтхб ы х лб б. (f, g) зтба бхзкыхн н х (h, i) лбыба бхзкыхн блй схшк ык шбст. 110 E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

7 g h i Figure 4. (a) Orthodontic treatment with camouflage. (b) Surgical exposure of symphysis. (c) Trial placement of Proplast at the recipient site. (d) Proplast preparation in antibiotic solution. Since Proplast is porous, it is rinsed with normal saline and placed in a 50 ml syringe containing 1 gr cephalosporin dissolved in normal saline. With appropriate manipulations we create vacuum in the syringe, so that the air trapped in the pores of the material is removed and replaced by the antibiotic. (e) Proplast placed in the proper position and fixated with screws. Patient s facial appearance (f, g) preoperatively and (h, i) postoperatively. х стхмк ыт шыfiл ыт. applefi ыкс с ошк ы с нохсхнрс н х ныхстотахнрс бзк- л ы с appleзты кнб applefi ытс тзт тсыхнfi к лб тс бх- зтзахн appleтн ы шы шк ык с л о лб тзтас хн бapple л шк, йт appleзткатл с к шбс appleзтбытхл - шб тзт тсыхн. шбс fiл б окшб с appleт- окб шб л ыfiшт лба ок бapple л шк н х ышх ыбохн appleзты лкшб ыкс о шк ыт тзт тсыхнт н лтйо apple з - о appleтсы ыкс хшкыхн х ы з appleт apple з лбсб. б ыкс тзт тсыхн бз appleб (тзт тсыхнfi н лт- йо ) хббы кнб к х ы з ык ш анобхшк н р н х тх applefiотхappleб обхытзахн х ы з (хн. 4a). с ыт ытх ыт хшкыхнfi appleзfi окл бм нтотт шб с apple з л сбх н р бс сыхлбы apple шкнб к шнбобыхн с - л о. ышх лбы applefi бapple сбны лкшк ык н ы шы шк шб кохн 19 бырс appleтй ш шкнб к боы шк ык блй сх- шк ыт appleзтшрappleт ык шбст лб лх лхнз шб з ыкы бхзтзахн бapple л шк fiapple к мкыхн абсбх- тappleо шыхн, зкшхлтappleтхрсы Proplast (Vitek, Inc., Dallas, Texas) хн. 4b,c,d,e). бapple л шк appleз ал ытappleтх кнб лб абсхн с хшкш н х к лбыба бхзкыхн н ы шы шк ык шбст бмбо кнб тл о. т хшк- ыхнfi appleты обшл apple змб хн стappleтхкыхнfi л ш лбы ыкс бapple л шк н х х ыкз кнб з н лх лбы то ах зтсхнfi х шыкл т бырс appleт х знбшб к лбыба бх- зкыхн apple з нтот кшк ык шбст (хн. 4f, g). case 1 presented above. Following consultation with the orthodontist, orthodontic treatment of the malocclusion was considered preferable instead of orthognathic surgery (sagittal split mandibular osteotomy). Orthodontic management of the malocclusion was satisfactory; however, chin hypoplasia remained an obvious severe esthetic problem for the patient, further accentuated by the presence of hooked nose. Augmentation genioplasty using the alloplastic material Proplast and simultaneous rhinoplasty by the same surgical team was considered as the treatment of choice. Surgery was performed under general anesthesia and included incision at the anterior vestibular area, subperiosteal placement of a 5 cm long and 1 cm thick piece of Proplast at the chin and fixation with three screws at the preselected position; a rhinoplasty was also performed simultaneously. Healing was normal and the final esthetic result was very satisfactory for the patient (Fig. 5b). No change in alloplastic material dimensions was found during the two-year follow-up; thus, patient esthetic appearance remained stable. DISCUSSION 2к appleбз appleы шк шбс кохн 22 бырс лб лхнзтас ык н ы ас - т appleб скнб шб тзт тсыхнfi ах хб ыкшк ык хшкыхн ык х ы з. appleт йтзт шб appleтappleо ш 111 It is known that, to date, there is no diagnostic guide that accurately defines those Class II cases needing orthodontic treatment combined with orthognathic surgery. Proffit and Ackerman (1994) proposed a E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

8 a b хнfiс 5. шбс (a, b) appleзтба бхзкыхн н х (c) лбыба бхзкыхн, лбы applefi шс шлfi мкыхн абсбхтappleо шыхн н х зхстappleо шыхн. c Figure 5. The patient (a, b) preoperatively and (c) postoperatively, following treatment with a combination of augmentation genioplasty and rhinoplasty. ыт абсб т (хн. 5a). applefi ык лбо ык ы с з хнрс ных- стаз йхрс н х ы с бнл аб с ык шбст х appleхшыркнб fiых бappleзfiнбхыт ах шанобхшх н с л о мк, н ыкатз 1 fiapple н х к appleзткат лбск шбс. apple с йбзб н х т тзт тсыхнfi applefi ы бз л ы appleт appleзт н с applefi ык лбо ык ык appleбз appleы шк нз кнб appleзтыхлfiыбзк к тзт тсыхн хб ыкшк ык ш анобхшк н х fi х к тзтас хн бapple л шк (т бох тшыбтытл ык н ы ас т). тзт тсыхн хб ыкшк нз кнб хн стappleтхкыхн н р бappleхыб кнб к злтсхн ш шк ы с т тсыхнрс ыfiм с, fiл к appleтappleо ш ыт абсб т бм нтотт шб с б с х блй с н х с appleтыбоб с шт зfi хшк- ыхнfi appleзfi окл ах ыкс шбс appleт м стсы с бappleхappleо - тс лб ыкс apple зтш р т л ык. ышх лбы applefi ш ыкшк ы с appleх срс о шб с ах ыкс хfiз шк ык хшкыхн х ы з appleзтыхл кнб к бappleхота ык мкшк ыт лба т ыт абсб т лб з шк ыт оотappleо шыхнт охнт Proplast н х ы ыfi зтск зхстappleо шых- н applefi ыкс х тл бхзтзарс. бapple л шк ахсб лб абсхн с хшкш н х лб ытл шыкс 112 diagnostic chart called the envelope of discrepancy. This envelope includes three asymmetric circles representing the range of correction that may be achieved with orthodontic treatment alone (inner circle), with growth modification combined with orthodontics (middle circle) and, finally, with orthognathic surgery (outer circle). The envelope of discrepancy is a useful tool for classifying the severity of Class II malocclusion; it cannot, however, determine treatment strategy because in clinical practice other factors are also involved, such as patient expectations, treatment options and clinician s experience (Proffit, 2000b). Proffit et al. (1992), on the basis of the results of treatment applied in patients with Class II malocclusion, found that orthodontic treatment does not lead to satisfactory results in certain cases. More specifically, when overjet is greater than 10 mm or the mandibular body is smaller than 70 mm, orthodontic treatment alone cannot correct the discrepancy. Facial height greater than 125 mm and pogonion point E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

9 хнfiс 6. б appleзт то шыт мтсб x н х y ык х схн шк ы с с н х н ы ытл с, т й нбот ш злтс б сбх ыт л абт ы с оо арс appleт лappleтзт с с бappleхыб т с Eш ыб- зхнfi н нот : лfiст лб тзт тсыхн бз appleб. бш т н нот : лб шс шлfi тзт тсыхн бз appleб н х ызтappleтappleт кшк ык мкшк. м ыбзхнfi н нот : лб тзтас хн бхзтзахн. шклбх б fiых к appleзт то шб т лfiст мт- сб бс сбх с ыfiыкы бны лкшк ык бз appleб шб ызхш- х шы ыт бapple appleб т. ао шшхн омк ы с ытл с б с х appleхт б нток applefi ыкс appleзтшытлх н лбы н скшк, fiapple бapple шк к appleбз нйшк шб ш шк лб ыкс бл хшк. ыкс appleбз appleы шк ык ызтappleтappleт кшк ык мкшк бйfiштс бс лappleтзб с а сбх бз appleбыхн apple з л шк шыкс н ы ас т сбм зыкы applefi ыкс с т лбш т н нот б с х хт ах ых т ас т. бхзтзахн хfiз шк ык л нзтас б с х бнтоfiыбзк ык бхзтзахн хfiз шк ык лхнзтас. (Proffit, 2000; с ы apple шк н ыfiappleхс б ) Figure 6. Overlaid on the x- and y- axes of ideal upper and lower incisor positions, the envelope of discrepancy shows the changes that may be achieved. Inner circle: orthodontic treatment alone. Middle circle: combination of orthodontic treatment and growth modification. Outer circle: orthognathic surgery. It should be noted that twodimensional imaging does not allow for treatment assessment on all three planes. Incisor retraction is easier to perform than labial movement; this is also true for extrusion as opposed to intrusion. In the case of growth modification, since the therapeutic intervention has to include the mandible and the maxilla, the middle circle is the same for both jaws. Surgical correction of macrognathia is easier than that of micrognathia (Proffit, 2000; reprinted after permission). appleзfiшх appleбзхт ык тотapple збх н о н бappleхо - кнб с ыбл хт Proplast л нт 5 cm н х apple т 1 cm ыт тappleт т шык шс бх ытappleтбы кнб шыкс абсбх н рз (appleтappleбзхтшыхн ) н х шык шс бх нхскытappleтх кнб лб ызбх б шыкс ыбохн шк appleт бappleхо кнб, бср ы - ыfi зтс appleз ал ытappleтх кнб н х зхстappleо шыхн. бappleт - о шк ыт ыз л ыт ы с тл о н х ыт ыбохнfi хшкыхнfi appleты обшл ахсб appleт бныfi лб лба ок хн стappleт кшк applefi ыкс шбс (хн. 5b). ыт х шыкл ы с т бырс ык лбыба бхзкыхн apple з нтот кшк бс х appleхшыркнб н лх лбы то шых х шы шбх ыт охнт н х шсбappleр н х шыкс хшкыхн блй схшк ык шбст. YZHTH H с х абатсfi fiых бс apple з бх л зх ш лбз с х - ас шыхнfi т каfi appleт лб б хfiыкы с н тз бх 113 positioned more than 18 mm behind the nasion perpendicular (to Frankfort horizontal) line are further signs indicating that orthodontic treatment alone will not provide satisfactory results. Practically, in order to manage a Class II patient with orthodontic treatment alone, the discrepancy between the upper and lower dental arches at the horizontal plane should not exceed the width of one premolar, because correction is usually achieved with two upper premolar extractions and retraction of anterior teeth (Thomas, 1995). Mandibular extractions should be better avoided in Class II malocclusion cases. When no severe crowding is present and anterior mandibular teeth are vertically positioned with healthy periodontium, expansion of the lower dental arch will solve the problem. Severe crowding, skeletal asymmetry and labial inclination of mandibular teeth are signs E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

10 appleтхб appleбзхappleыршбх мк apple хы штс бныfi applefi ыкс тзт тсыхн бз appleб, бappleхappleо тс н х тзтас хн бхзтзахн. applefi ыт Proffit н х Ackerman (1994) appleзты кнб с х ас шыхнfi apple с н appleт тстл бы х й нбот ш злтс (envelope of discrepancy). й нбот ыfi (хн. 6) appleтыбоб ы х applefi ызбх ш ллб- ызт н нот appleт apple зхшыт с ы fiзх ык хfiз шк appleт лappleтзб с appleз ал ытappleтхкб лб тзт тсыхн бз - appleб (бш ыбзхнfi н нот ), лб ызтappleтappleт кшк ык мкшк шб шс шлfi лб тзт тсыхн (лбш т н нот ) н х ы от лб тзтас хн бapple л шк (бм ыбзхнfi н нот ). й нбот ш злтс appleтыбоб с з шхлт т - кл ах ыкс ы мхсfiлкшк ык з ыкы ык шанобх- шх н с л о ы с шбсрс лб мк, бс лappleтзб fiл н х с н тз шбх ыкс бз appleб appleт нтоткб н х ыfi ах ы шыкс нохсхн appleз мк ах ыкс ыбохн бappleхота ыт бз appleбыхнт ш б т appleбхш з тсы х н х оотх apple з атсыб fiapple тх appleзтш тн б ыт шбст, тх бappleхота н х к блappleбхз ыт х ызт (Proffit, 2000b). б шк ы appleтыбо шл ы applefi ык бз appleб appleт бй з- лfiшкнб ах ыкс сыхлбырappleхшк ы с шбсрс лб шанобх- шх н с л о мк х appleхшыркнб applefi ыт Proffit н х шс. (1992), fiых к тзт тсыхн бз appleб бс apple зтшх бх хн стappleтхкыхн appleтыбо шл ы шб тзхшл сб appleбзхappleыршбх. х хнfiыбз fiы с к тзхfiсых appleзfiы мк б с х лба о ыбзк applefi 10 mm ыт л нт ыт шрл ыт ык н ы ас т лхнзfiыбзт applefi 70 mm к тзт тсыхн бз appleб applefi лfiск ык бс лappleтзб с appleтн ы шы шбх ыкс х ы з. apple шк fiы с ыт т ыт appleзтшрappleт б с х лба о ыбзт applefi 125 mm н х ыт apple арсхт з шнб- ы х appleбзхшшfiыбзт applefi 18 mm apple ш applefi аз лл appleт й збы х н бы applefi ыт зхтзз схт шыт бapple appleб т ык з снйт зык (nasion perpendicular) appleтыбот с оо бс бхныхн шытх б ах ыкс appleтйа хбс забх лfiст ык тзт тсыхн бз appleб. з ныхн ах с бй злтшб тзт тсыхн бз appleб шб шбс лб мк, appleз appleбх к х йтз ыт с лб ыт н ы т тсыхнfi ыfiмт шыт тзхfiсыхт бapple appleб т с лкс б с х лба о ыбзк applefi ыт appleо ыт бсfi appleзтатлй т ах ы к хfiз шк шс бappleхыа сбы х лб ыкс омк appleзт ы apple ш ы с с appleзтш с тсыхрс йт appleзткатл с а сбх бм а а бсfi appleзтатлй т applefi н б appleобз (Thomas, 1995). х бм а а шыкс н ы ас т б с х appleзтыхлfiыбзт с appleтйб атсы х шых appleбзхappleыршбх шанобхшх нрс с л - охрс мк. ышх fiы с бс apple з бх сытст шс шых- шлfi н х ы appleзfiшх fiсых ык н ы ас т тс н ы нfiзйк шк лб ах appleбзхт fiсыхт, ыfiыб лб ык хб - зсшк ыт н ы т тсыхнт ыfiмт хббыт сы х н х ы fiсых appleт з шнтсы х бныfi ыfiмт. сытст т тсых- нfi шс шыхшлfi, к шнбобыхн шллбыз н х к бхохн applefiнохшк ы с тсыхрс ык н ы ас т appleтыбот с бс б мбх ах бм а а тсыхрс applefi ыкс н ы ас т (Thomas, 1995). с ыт ытх ы appleтыбо шл ы ык тзтас хнрс бappleбл - шб с fiшт йтз ыкс хшкыхн блй схшк ыт appleзтшрindicating that extractions in the lower jaw should be performed (Thomas, 1995). However, in regard to esthetic appearance, orthognathic surgery results are significantly superior to those achieved by orthodontic treatment alone (Dunlevy et al., 1987; Proffit et al., 1992). Thus, patients with mandibular hypoplasia who underwent orthodontic treatment combined with orthognathic surgery showed greater esthetic improvement compared to patients who underwent orthodontic treatment alone (Proffit et al., 1992). In cases where orthognathic surgery is the treatment of choice, the patient should also be informed about possible complications involved in such procedures. Certain complications usually persist for a short time (such as postoperative hemorrhage, pain and edema), whereas others, such as neurosensory disorders last for several weeks or months (Tucker, 1995). However, even orthodontic treatment of Class II malocclusion may sometimes cause root resorption of upper incisors (Kaley and Phillips, 1991). It seems that the treatment of choice in marginal Class II cases also depends on the clinician who is usually the first the patient consults (Cassidy et al., 1993). However, the majority of patients seem to favor a conservative approach achieved with orthodontic treatment alone, while fewer patients choose the surgical option (Thomas, 1995). In cases treated conservatively, the esthetic problem often persists due to mandibular micrognathia. Certain reference lines familiar to both orthodontists and maxillofacial surgeons may be used to assess chin protrusion in such cases. These lines reveal the relationships between chin, lips and nose (Tweed, 1945). Thus, in certain Class II patients, extractions of mandibular teeth are necessary so that a harmonious chin relationship may be achieved. However, occlusal restoration demands retraction of maxillary anterior teeth, which in turn creates another esthetic problem, as the nasiolabial angle increases and the nose becomes more protrusive. Correction in these cases may need complementary rhinoplasty. Nevertheless, the esthetic problem mainly due to chin deficiency is better managed with a relatively simple procedure involving the symphysis (Proffit, 1981). Augmentation genioplasty, besides significantly improving facial esthetics, also contributes to stability of the final result achieved with orthodontic treatment; surgical anterior chin displacement also displaces the lower lip, thus relieving the pressure applied on lower incisors (Proffit, 1978). Consequently, genioplasty may constitute an adjunctive procedure with favorable results in cases treated with orthodontics alone (Proffit, 1981). Genioplasty may also be performed on patients with Class II presenting also skeletal mandibular asymmetry. 114 E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

11 appleт appleбз тс шкл сыхн applefi ы сы шытх appleтыбо - шл ы appleт бappleхыа стсы х лб ыкс тзт тсыхн бз - appleб (Dunlevy н х шс., 1987; Proffit н х шс., 1992). ышх шбсб лб appleтappleо ш ык н ы ас т appleт appleт- о кн с шб шс шлfi тзт тсыхн бз appleб н х тзтас хн бapple л шк блй схш с лба о ыбзк бо- ы шк шыкс хшкыхн ыт appleзтшрappleт шб ш шк лб ыт шбсб appleт appleт о кн с лfiст шб тзт тсыхн бз appleб (Proffit н х шс., 1992). ых appleбзхappleыршбх fiл appleт бappleхо абы х н х к тзтас хн бхзтзахн appleз appleбх с бсклбзрсбы х т шбс н х ах ых appleх - с бappleхappleотн appleт шст б тс ы ытхб бappleбл шбх. appleтхб applefi ых бappleхappleотн шс бappleхл стс ах лхнзfi зтсхнfi х шыкл (fiapple к лбыба бхзкыхн хлтз- з а, т applefiст н х ыт т кл ), бср ооб fiapple тх сб- зт хшкыхн х ы з х знт с бapple лбзхн б т- л б л сб (Tucker, 1995). с ыт ытх н х к тзт- тсыхн бз appleб appleт appleз ал ытappleтхб ы х шб шанобхшх - н с л о б мк лappleтзб тзхшл сб йтз с appleзтн о шбх appleтззfiйкшк ы с зхрс ы с с ытл с (Kaley н х Phillips, 1991). ныfi applefi ых apple з л ызт appleт appleзт с й зкн с й - сбы х fiых к бappleхота ык бз appleб шых тзх н appleбзхappleыр- шбх ык мк бм зы ы х н х applefi ытс бх хнfi шытс тappleт т appleбсб ах appleзрык йтз т шбс (Cassidy н х шс., 1993). appleобхт кй fiл ы с шбсрс й сбы х fiых appleзтыхл ыкс шсыкзкыхн сыхлбырappleхшк appleт бappleхыа сб- ы х лб тзт тсыхн бз appleб н х охаfiыбзтх шбсб бappleх- о атс ык бхзтзахн бз appleб (Thomas, 1995). ых appleбзхappleыршбх fiл appleт бй злfiбы х к шсыкзкыхн сыхлбырappleхшк ш с apple з л сбх ыт хшкыхнfi appleзfi окл бм хы ык лхнзтас. appleзтapple ыбх ыт абсб т шых appleбзхappleыршбх ы лappleтзб с бныхлкб лб ык з - мк х йfiз с аз ллрс с йтз лб ых тappleт б б с х бмтхнбх л стх ыfiшт тх тзт тсыхнт fiшт н х тх ас т- бхзтзат. б ых аз лл ы х appleхшырсбы х к ш шк лбы м ыт абсб т, ы с бхо с н х ык л ык (Tweed, 1945). ышх шб лбзхнт шбсб лб с л о мк й - сбы х fiых б с х apple з ыкык к бм а а тсыхрс applefi ыкс н ы ас т ах с бappleхыб б злтсхн ш шк лб ыт а сбхт. х с appleтн ы шы б к ш анобхшк fiл шых appleбзхappleыршбх ы apple хыб ы х лбы н скшк appleзт ы apple ш ы с appleзтш с тсыхрс ык с ас т appleт лб ык шбхз ык клхтзаб с с т хшкыхнfi appleзfi окл н р м сбх к зхст бхохн а с н х ытс бы х сытс к л ык. сбappleр к хfiз шк шых appleбзхappleыршбх ы лappleтзб с apple хы шбх ыкс бй злта зхстappleо шыхн бapple л шк. х ы з fiл ы appleт тйб обы х нз шыкс appleтappleо ш ыт абсб т хббыб ы х н о ыбз лб ыкс бй з- лта лх appleо ш быхн бapple л шк шыт а сбхт (Proffit, 1981). мкыхн абсбхтappleо шыхн бныfi applefi ык шкл - сыхн боы шк ык хшкыхн ыт appleзтшрappleт, шл о- обх н х шык шы бзfiыкы ыт appleтыбо шл ыт appleт бappleхыб - кнб лб ыкс тзт тсыхн бз appleб ах ы лб ыкс appleзfi- шх лбы н скшк ыт абсб т лбы нхсб ы х н х ыт н ы б In these cases the teeth are displaced relative to the apical base, due either to adaptations during growth or to dental movements during orthodontic treatment. The main issue in these patients is the esthetic problem created by chin displacement. They are optimally managed with genioplasty and not mandibular sagittal split osteotomy, because the latter disrupts the occlusal result already achieved with orthodontic treatment and creates further problems (Proffit, 1981). Augmentation genioplasty is achieved either with placement of alloplastic materials on the anterior chin surface or with sliding osteotomy without using implants. Soft tissue displacement with sliding osteotomy is estimated at 60-70% and therefore this displacement is highly predictable (Bell and Dann, 1973). Proplast has been the alloplastic material used for many years and recently Medpor (Porex, Newnan, U.S.A.) (porous polyethylene) has started being used. However, it is claimed that for both materials soft tissue displacement is not as predictable as that achieved with sliding osteotomy. Our experience with Proplast is excellent and, as we report in the clinical cases presented above, the result was stable after two years in both cases. In conclusion, genioplasty constitutes a satisfactory procedure for the management of patients with Class II malocclusion. REFERENCES Bell WH, JJ Dann. Correction of dentofacial deformities by surgery in the anterior part of the jaws. Am J Orthod 1973;64, Cassidy DW, Herbosa EG, Rotskoff KS. A comparison of surgery and orthodontics in borderline adults with class II, division 1 malocclusions. Am J Orthod Dentofacial Orthop 1993;104: Dunlevy HA, White RP, Proffit WR. Professional and lay judgment of facial esthetic changes following orthognathic surgery. J Adult Orthognath Surg 1987;2: Epker BN, Fish LC. The surgical-orthodontic correction of mandibular deficiency. Part II. Am J Orthod 1983;84: Kaley JA, Phillips C. Factors related to root resorption in edgewise practice. Angle Orthod 1991;61: Kolokithas G, Zafiriadis A, Topouzelis N, Kavvadia S, Ioannidou I, Sidiropoulou S. Class II/1 Malocclusion in Northern Greece. An Epidimiological Study. Stoma : Kolokithas G, Ioannidou I, Kavvadia S, Sidiropoulou S, Topouzelis N, Zafiriadis A, Markovitsi E. Epidemiologic study of dental and dentoalveolar discrepancies in orthognathic children. Orthod Rev 1989;1: E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

12 от тapplefiыб лбхрсбы х к apple бшк appleт шнб ы х шыт н ы ытлб (Proffit, 1978). сбappleр к абсбхтappleо шыхн лappleт- зб с бй злтшб ш с шлappleокз л ыхн бз appleб шб шбсб appleт сыхлбы apple шкн с лб тзт тсыхн бз - appleб н х appleтн ы шы кнб к ш анобхш ыт, бм нтотт ш с fiл с х ыкзт с ыкс appleтappleо ш ыт абсб - т. ыт шбсб ыт к мкыхн абсбхтappleо шыхн бх ббзабыхн appleтыбо шл ы (Proffit, 1981). абсбхтappleо шыхн лappleтзб с зкшхлтappleтхкб бapple шк шб шбсб appleт бныfi applefi ыкс мк блй с тс н х шнб- обыхн шллбыз шыкс н ы ас т. ых appleбзхappleыршбх ы ы fiсых б с х apple збнытappleхшл с appleзт ык шк ык н ы ас т б ыб бм хы appleзтш злтарс appleт appleз а- л ытappleтхт сы х н ы ык х знбх ык с appleымк б ыб applefi ых лбы нхс шбх appleт appleз ал ытappleтхт сы х шык х знбх ык тзт тсыхн бз appleб. ыт шбсб ыт ыт н зхт appleзfi окл б с х к шлтзй appleт appleзтн об к apple збныfiappleхшк ыт абсб т. н о ыбзк сыхлбырappleхшк ы с шбсрс ырс бappleхыа сбы х лб абсбхтappleо шыхн н х fi х лб т бох тшыбтытл ык н ы ас т ах ы лб ыкс ыбобы х ы з шшбы х к ш анобхшк appleт бх бappleхыб- б лб ыкс тзт тсыхн бз appleб н х клхтзаб appleбзхшшfiыбз appleзт о л ы apple з бappleхо бх ы к apple з- тсы (Proffit, 1981). мкыхн абсбхтappleо шыхн бappleхыа сбы х б ыб лб ыкс ытappleт ыкшк оотappleо шыхнрс охнрс шыкс appleзfiшх бappleх- й сбх ыт абсб т б ыб лб тохшкыхн тшыбтытл з ык зкшхлтappleт кшк блйыбл ыхнрс охнрс. б ыкс тох- шкыхн тшыбтытл к лбы н скшк ы с л о нрс лтз с appleтота бы х шб 60-70% н х шсбappleр ы к лбы н ск- шк б с х appleзт о хлк шб с коfi appleтштшыfi (Bell н х Dann, 1973). applefi ы оотappleо шыхн охн бappleхнз ыкшб ах appleтоо зfiсх к зкшхлтappleт кшк ыт Proplast н х ыбобы ыт Medpor (Porex, Newnan, USA) (appleтзр- б appleто хо схт) ах ы тappleт fiл appleтшыкз бы х fiых к лбы н скшк ы с л о нрс лтз с бс б с х ыfiшт appleзт о хлк fiшт к лбы н скшк appleт бappleхыа сбы х лб ыкс тохшкыхн абсбхтappleо шыхн. apple тлб х appleхшыршбх applefi ыкс хн л блappleбхз applefi ык зкшхлтappleт кшк ыт Proplast ы appleтыбо шл ы applefi ыкс бй злта ыт ы с бм хзбыхн н х fiapple с - й з лб н х шыкс apple зтш шк ы с appleбзхшы ыхнрс ыт appleт- ы обшл лбы applefi т зfiсх apple з лбхсб лбы окыт н х шых т appleбзхappleыршбх. зкшхлтappleт кшк шсбappleр ык абсбхтappleо шыхн appleтыбоб лх хн стappleтхкыхн appleзт- ш аахшк ах ыкс бapple ошк ы с appleзт окл ы с appleт apple зт- шх бх к сыхлбырappleхшк ы с шбсрс лб шанобхшх н с л о мк. хб сшк ах с ыapple : сшы сы ст з к кыз. бсс т ёбшш отс нк Kolokithas G, Sidiropoulou S, Kavvadia S, Topouzelis N, Ioannidou I, Zafiriadis A. Results of an epidemiological study on a sample of Greek adolescents in Northern Greece. Hellenic Stomatological Review 1990;34: Kolokithas G, Sidiropoulou S, Zafiriadis A, Ioannidou I, Topouzelis N, Markovitsi E. Epidemiological study of the problems of the stomatognathic system of school children in the county of Thessaloniki, Greece. Stoma 1992;20:73-81 Nelson C, Harkness M, Herbison P. Mandibular changes during functional appliance treatment. Am J Orthod Dentofacial Orthop 1993;104: Proffit WR, Ackerman JL. Diagnosis and treatment planning. In: Graber TM, Vanarsdall RL, Jr, eds. Orthodontics. Current principles and treatment. St Louis: Mosby, Proffit WR, Field HW. Combined surgical and orthodontic treatment. In: Proffit WR, ed. Contemporary Orthodontics. St. Louis: Mosby, 2000: Proffit WR, Field HW. Malocclusion and dentofacial deformity in contemporary society. In: Proffit WR, ed. Contemporary Orthodontics. St Louis: Mosby, 1993:7-8 Proffit WR, Phillips C, Douvartzidis N. A comparison of outcomes of orthodontic and surgical-orthodontic treatment of Class II malocclusion in adults. Am J Adult Orthod Dentofacial Orthop 1992;101: Proffit WR, Turvey TA, Morariarty J. Augmentation genioplasty as an adjunct to conservative orthodontic treatment. Am J Orthod 1983;79: Proffit WR. Interview. Hell Orthod Rev 2000b;3:9-19. Thomas PM. Orthodontic camouflage versus orthognathic surgery in the treatment of mandibular deficiency. J Oral Maxillofac Surg 1995;53: Tucker MR. Orthognathic Surgery versus orthodontic camouflage in the treatment of mandibular deficiency. J Oral Maxillofac Surg 1995;53: Tweed CH. A philosophy of orthodontic treatment. Am J Orthod Oral Surg 1945;31: Reprint requests to: Konstantinos Lazarides Mitr. Gennadiou Str. 10 GR Thessaloniki Greece E HNIKH E IёEЬPH H 2004 Я TOMO 7 HELLENIC ORTHODONTIC REVIEW 2004 Я VOLUME 7

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