Unveiling the risk factors behind melasma: An observational study

Background: Melasma is a common, acquired, recurrent and chronic disorder of hypermelanosis. It is distributed symmetrically and affects the sun-exposed areas mainly the face (forehead, cheeks, upper lip and chin), and manifests as light to dark brown patches of hyperpigmentation. The objective of this study is to identify the major predisposing and aggravating factors of melasma. Materials and methods: This was an observational, cross-sectional study, conducted in the Dermatology OPD of Meenakshi Medical College, among 100 patients with melasma for a period of 18 months. Melasma was diagnosed clinically and using Wood’s lamp examination. Factors such as the age at presentation, gender, duration of sun exposure per day, family history, intake of precipitating drugs and systemic diseases were assessed. Results: Most of the patients were in the age group of 36-45 years and the majority of patients were females. Sun exposure for >2 hours was observed to be an important triggering factor. Positive family history was present in 46% patients, 12 patients had a history of intake of precipitating drugs and 30 patients had systemic diseases. Conclusion: It can be concluded from this study that the above factors play a significant role in the development and prognosis of melasma. Sun exposure for longer duration was observed to be a very important factor, especially because of the climatic conditions prevailing here. So elimination of the exacerbating factors and treatment of associated systemic conditions are important in the management along with the therapeutic agents.

Atrial myxoma: 14 years experience

Introduction: Cardiac tumors constitute only 0.2% of all tumors. Primary cardiac tumors occur infrequently with an incidence of 0.0017% to 0.19%, estimated on autopsies performed in non-selected populations. Left atrial myxomas are the most prevalent [75% to 80%] and right atrial are less common [10% to 18%]. Surgical excision yields an excellent prognosis and recurrence rate of only 3% with a very low morbidity and mortality

Objective: We aimed to review our experiences with this rare entity and highlight the various aspects of myxoma presentation, diagnosis and outcomes

Methodology: A retrospective chart review done on patients underwent excision of myxoma with histopathological confirmation since January 1991 till December 2015. Standard surgical approach adopted was single atrial, augmented with Biatrial approach where needed

Results: A total 42 cases were identified and 28 cases with complete data were included in the analysis. Mean age was 54.4 [ +/- 17.7] years, with female predominance [58% vs. 42%]. Preoperative comorbidities included hypertension [39.2%], diabetes [28.5%], IHD, dyslipidemia, and COPD [10.7%] that were comparable among gender. The mean dimension of myxoma measured on echocardiography was 4.9x3.5x2.7 cm. Sixty four percent had left sided and 35.7% had right sided myxoma. Most common symptom was dyspnea [71%], constitutional symptoms [39.3%] and stroke in [18%]. Echo being the diagnostic modality of choice. Post-operative complications occurred in 6 patients and mortality occurred in 2 [7.2%]. Mean post-operative follow up was 8.3 months and 10 years telephonic follow up completed in [32%] cases, with 2 late non-cardiac mortalities

Conclusion: Our results showed that the prevalence of cardiac myxoma is comparable with global estimates. Female gender was predominant and age and right atrial myxoma was slightly higher in our sample compare to other published literature. Myxoma can be excised successfully with a low rate of morbidity, mortality and recurrence

Radiation doses from [131]I treated hyperthyroidism patients versus life style: - a survey

Radioactive iodine is widely used for the treatment of various thyroid disorders. Safety issues are often a source of worry and anxiety for the patients, their families and comforters. The patients are advised to restrict their social and work related activities. The work presented in this study describes the results of a structured survey conducted on patients visiting our hospital. The total number of patients inducted was 419. The patients were asked about their housing conditions, family set up, number of children, travelling modes and travelling time back to home. The hospital leaving exposure rates from the patients were measured and radiation doses to others were estimated. Patients residing in joint family system were 93%. The measured dose rate at one meter were 5.7, 11.0, 15.7, 18.7, 23.0 and 28.0 micro Svh-1 for the administered [131]I activity of 185, 370, 555, 740, 925 and 1100 MBq respectively. The corresponding radiation doses to others from the patient were estimated as 0.76, 1.53, 2.29, 3.06, 3.82 and 4.58 mSv. The patients using public transport were 78.04% whereas 21.96% used private transport. There were 11.93% of the patients with no children and 88.07% of the patients had children residing with them. It was observed that 1.67% of the patients had no toilets at home and 98.33% had multiple toilets available. The radiation protection advice and regulatory requirements need to be formulated keeping in view the individual patient life styles and other living conditions

Accuracy of 12 lead ECG for diagnosis of posterior myocardial infarction

To determine the accuracy of 12 lead ECG for diagnosis of acute Posterior Myocardial Infarction [MI] after its confirmation by 15 leads ECG. This study was conducted in Cardiology Department, Lady Reading Hospital Peshawar from January to July, 2012. Patients presenting to CCU with typical chest pain, pain epigastrium, sweating, nausea or vomiting and with admitting diagnosis of acute coronary syndrome [ACS] were included. The diagnostic criteria for posterior MI on 12 leads ECG was when R:S was more than 1:1 in V2 or there was tall R wave in V1 or V2 [more than Sin the same leads] or more than 2mm ST segment depression in anterior lead. Posterior MI was confirmed on 15 leads ECG taking it as a standard when ST segment elevation of >1mm was present in C7,8,9. Out of 176 randomly selected patients, 90[51.1%] were male and86[48.9%] female; with mean age of 63 years. Out of these, 70 were in the age range of 51 to 60 years and 40 each in 41-50 and 61-70 years. Eighteen patients had changes of posterior MI on 12 leads ECG and amongst them 10patients had true posterior MI on 15 leads ECG. We had 8 false positive cases on 12 leads ECG with no false negative cases after confirmation with 15 leads. The accuracy of 12 leads ECG for detection of posterior MI was55% after confirmation with 15 leads and there was no age and gender difference in its accuracy

Effect of cholesterol level on platelet aggregability in normal individuals

The aim of present study was to find the effect of cholesterol level on platelet aggregability in normal individuals. This study was conducted in Cardiology department, Lady Reading Hospital, Peshawar in September-October 2007. Normal individuals aged 18 years or above were randomly included. Patients who were suffering from any cardiovascular or other diseases were excluded. Those who were taking ante-platelets, anti coagulants and lipid lowering drugs were also excluded. Thus a total of 101 individuals were examined, after taking informed written consent. Fasting blood samples were taken from each patient. Total cholesterol was measured in hospital laboratory, while platelet aggregation was measured with chronolog whole-blood platelet aggregometer [WBA]. A total of 101 patients were examined. Their mean age was 51.24 +/- 8.23 years. Male were 60[59.41%] and female were 41[40.59%]. Mean platelet aggregability of these individuals was 7.87 +/- 4.40 ohms. Mean cholesterol was 163.47 +/- 20.75 mg/dl. When age was correlated with aggregability, both had a weak negative correlation. Pearson correlation coefficient was -.018 [p=0.855]. When age was correlated with cholesterol, again both have a weak negative correlation. Pearson correlation coefficient was -.152 [p=0.129]. When aggregability was correlated with cholesterol, both have a significant positive correlation. Pearson correlation coefficient was +0.269 [p=0.006]. Platelet aggregability is increased in patients with high cholesterol. These patients may need higher doses of anti platelets and more aggressive treatment of lipids to avoid vascular events

Frequency of aspirin resistance in patients with cardiovascular diseases

To find out the frequency of aspirin resistance, as measured by the inhibition of platelet aggregation, using Whole Blood Aggregometery, in patients with cardiovascular diseases presenting to out patient department of a tertiary care hospital. This study was conducted in the outpatient department of Cardiology, Lady Reading Hospital Peshawar, from October 2007 to January 2008. A total of 105 normal individuals not taking aspirin and 136 patients taking aspirin for cardiovascular diseases were randomly included. Blood was taken for measuring platelet aggregation using whole blood aggregometer. Result of each individual was noted on a proforma. Patients who were on any other ante-platelet like clopidogrel; or on warfarin and heparin were excluded from the study. Chi -square and independent t-test were used to find significant differences between different groups and variables. Platelet aggregability in 105 normal subjects, not taking aspirin was 9.28 +/- 3.23ohms. So cutoff for aspirin non responsiveness was taken as 9.28-3.23=6.0 ohms. Mean aggregability of 136 cardiovascular patient, taking aspirin was 5.81 +/- 5.47 ohms. Mean age was 52.66 +/- 10 years.Male were 80[58.8%]. Patients having aggregability >/= 6 ohms were 47.1%[n=64]. Mean aggregability of male patients was 5.66 +/- 5.45 ohms. Mean aggregability of female patients was 6.03 +/- 5.54 ohms[p=0.69]. When age was correlated with aggregability, both have a weak negative correlation [Pearson correlation coefficient= - .109 [p=0.205]. Mean age of patients having aggregability /= 6 was 51.46 +/- 10.36 [p=0.19]. Aspirin resistance as defined by inhibition of platelet aggregation measured with Whole Blood Aggregometry, is a common problem. Gender and age has no significant affect on platelet aggregability

Efficacy of a single dose intravenous heparin in reducing sheath-thrombus formation during diagnostic angiography: a randomized controlled trial

Femoral arterial sheath thrombosis and distal embolization are well-recognized complications of cardiac catheterization but the occlusion is extremely rare. Heparinized saline flushes are used during diagnostic coronary angiography to prevent thrombus formation within the sheath lumen. However, the use of prophylactic intravenous heparin following the femoral arterial sheath insertion is controversial. The aim of this study is to evaluate the effectiveness of 2000 units of intravenous heparin bolus in comparison to a saline placebo on the thrombus formation within the arterial sheath during the diagnostic coronary angiography. Eligible patients were randomized to receive either a study drug or placebo at the time of femoral sheath insertion. The sheath was aspirated and flushed for any presence of thrombus after each catheter exchange and at the end of the procedure. Five milliliters of blood were extracted and visualized on clean gauze followed by a saline flush. The primary end-point was the effectiveness of the study drug on reducing the incidence of sheath-thrombus formation. Three hundred and twenty patients were randomized into two arms. Three hundred and four patients were analyzed: 147 patients in heparin arm and 157 patients in placebo arm after exclusion of 13 patients in heparin arm and three in placebo arm because of incomplete reports. The baseline characteristics were similar and sheath-thrombi formation was observed in 20% of the total cohort. Of the heparin arm, 12% [19 patients] developed sheath-thrombus formation, whereas 26% [42 patients] in the placebo arm, p-value = 0.002. An adjusted logistic regression model showed that the only predictor for the sheath-thrombus formation was the study drug [i.e. heparin]. The odds ratio of developing a thrombus in the control arm was 2.5 [95% CI: 1.4-4.5, p = 0.003]. There were no bleeding events observed. The risk of thrombus formation is significant and intravenous heparin significantly reduced thrombus formation during diagnostic coronary angiography, with no excess bleeding events

comparative analysis of in-hospital left ventricular function in patients with successful or unsuccessful streptokinase thrombolysis following acute myocardial infarction

To compare in-hospital left ventricular function in patients with unsuccessful and successful thrombolysis presenting with acute myocardial infarction treated with streptokinase. This comparative study was conducted at department of Cardiology, Lady Reading Hospital Peshawar, from October 2006 to October 2007. Two hundred patients with first acute myocardial infarction were divided into two groups: group A [successful thrombolysis] and group B [unsuccessful thrombolysis], using ECG criteria. To determine Left Ventricular Function, 2-D Echo was used. Group A included 136 [68%] patients and group B included 64 [32%] patients. Impaired left ventricular function was found in 41 [30.1%] patients in group A and 41 [64.1%] patients in group B [p< 0.001]. Left ventricular failure was present in 31 [22.8%] patients of group A and 30 [46.9%] patients of group B [p=0.001]. Cardiogenic shock was diagnosed in 2 [1.5%] patients in group A and 6 [9.4%] patients in group B [p-0.008]. Presence of LVF is strongly associated with unsuccessful thrombolytic therapy in this group of patients

Prevalence of hyperlipidemia in obese and non obese coronary artery disease patients

To determine the prevalence of hyperlipidemia in obese and non-obese patients with diagnosed coronary artery disease. This hospital based descriptive study was conducted in Cardiology Department of Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from 15[th] March 2005 to 30[th] May 2006. A total of 200 patients with diagnosed coronary artery disease were enrolled, 100 were classified as obese and 100 as non-obese. There were 139 males and 61 females in total 200 CAD patients. Serum triglycerides level was 184 +/- 82 in obese patients and 158 +/- 68 in non-obese patients [p = 0.015]. Serum cholesterol level was 208 +/- 61 in obese and 180 +/- 67 in non obese [p = 0.001]. Serum HDL level was significantly more in non obese [48 +/- 36] as compared to obese [37 +/- 8] [p =0.005]. Serum LDL was more [157 +/- 49] in obese as compared to [148 +/- 44] in non obese but with no statistical difference [p =0.156]. Obese CAD patients had significantly had higher levels of triglycerides, total cholesterol with lower HDL levels as compared to non obese CAD patients

Comparison of effect of locally available brands of clopidogrel on platelet aggregation in patients with coronary artery disease

Anticoagulant effect of clopidogrel is of utmost importance in coronary artery disease, especially in prevention of coronary stent thrombosis. Recently, many new local brands of clopidogrel have been launched, with unknown efficacy. This study was conducted with the aim to compare two locally prepared clopidogrel brands, in terms of the effect of a loading dose of 600 mg on inhibition of platelet aggregation in patients with coronary artery disease. This was a double blind randomised study. Sample population consisting of 35 patients, were admitted at Lady Reading Hospital, Peshawar, for the management of coronary artery disease. Baseline platelet aggregation of all these patients was measured. These patients were divided in two groups randomly. Group-A consisting of 18 patients was given brand 'A' clopidogrel 600 mg, while Group-B consisting of 17 patients was give brand 'B' of clopidogrel 600 mg. The platelet aggregation of both groups was then measured at baseline, and at 2, 4, and 6 hours after taking the loading dose of 600 mg. Platelet aggregation time at baseline in Group-A was 2.61 +/- 2.28 sec. and in Group-B it was 2.24 +/- 1.52 sec. [p=0.57]. After 2 hours of clopidogrel administration in Group-A the platelet aggregation time was 1.44 +/- 1.58 sec. and in Group-B it was 1.53 +/- 1.107 sec. [p=0.85]. Platelet aggregation time after 4 hours in Group-A was 0.28 +/- 0.57 sec. and in Group-B 1.06 +/- 1.03 sec. [p=0.009], and after 6 hours it was 0.00 +/- 0.00 sec. in Group-A and in Group-B it was 0.59 +/- 0.71 sec. [p=0.001]. The two brands of clopidogrel had a significant difference in their effect on inhibition of platelet aggregation. Different brands of clopidogrel may not be equally effective

Prevalence of class II malocclusions in Pakistani sample - a study

The aim of this study was to determine the frequency of Class II malocclusion in seven different age groups in a local sample of patients seeking orthodontic treatment. Data for the study were retrieved from the patient's orthodontic records who sought orthodontic treatment at Armed Forces Institute of Dentistry [AFID] during the period of Oct 1999 through May 2008. A total of 1348 patients were screened. All the subjects had full complement of permanent teeth up to second molars. The patients with the history of previous orthodontic treatment, extractions of permanent teeth other than 3rd molars, mixed dentition, congenital malformations like Cleft lip or/ and palate and systemic diseases were excluded from the study. Assigning the subjects to various occlusal traits was based purely on clinical examination, study casts in centric occlusion, facial photographs and lateral cephalograms assessment. An overall prevalence of class II malocclusions within the selected sample was found to be 41%, with a male to female ratio of 1: 2.6. The three categories of Angle Class II malocclusion depicted a prevalence of 29.9% for Class II/1, 0.7% for Class II/2 and 10.4% for Class II subdivisions. All the three groups of Class II malocclusions reflected higher female ratios, presumably because of the higher number of female gender seeking orthodontic treatment in Pakistan

Frequency and etiology of midline diastema in orthodontic patients reporting to armed forces institute of dentistry Rawalpindi

To determine the frequency and etiology of maxillary midline diastema [MMD] in local settings. Descriptive study. The study was carried out on orthodontic patients reporting to Armed Forces Institute of Dentistry Rawalpindi [AFID] from 2001 to 2007 at the Department of Orthodontics, Armed Forces Institute of Dentistry Rawalpindi. A total of 1800 cases of malocclusions, were collected from orthodontic dept of AFID Rawalpindi, during research period. Sample purification resulted in a research sample of 1747 patients. The data of all patients was analysed as regards to age, gender, occlusal traits, and relevant disatema findings. The frequency of MMD turned out to be 12.59%. No single etiological factor was found responsible for MMD, however increased over jet was the most frequently [56.56%] occurring factor related to MMD, followed by high frenum attachment [33.03%] and finally deep bite, 31.6%. Maxillary midline diastema is a common entity associated with multifactorial etiology. Focusing on symptomatic treatment rather than addressing the cause oriented approach will lead to relapse of the already existing problem. Permanent retention should be considered in most cases

Grown up Congenital Heart Disease patient presenting for non cardiac surgery: anaesthetic implications

Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. These patients are admitted in the hospital for non cardiac surgeries and other procedures more often than normal adult population. Management of grown up congenital heart disease patient presents a challenge during perioperative period for cardiologists, surgeons, intensivists and particularly for the anaesthetist. Management issues include psychological and physiological impact on the patient, complexity of defects, presence of previous palliative procedure, impact of anaesthetic agents on shunting and myocardium, endocarditis prophylaxis and associated extra cardiac anamolies

Prevalence of asymptomatic left ventricular diastolic dysfunction in normotensive type 2 diabetic patients

To determine the frequency of asymptomatic left ventricular diastolic dysfunction in normotensive type 2 diabetic patients. This descriptive case series study was conducted on 80 normotensive Type 2 diabetic patients at Cardiology Department, PGMI Lady Reading Hospital Peshawar from March 2007 to March 2008. Detailed history and physical examination was performed on every patient. The glycemic status was defined on the basis of HbA1c. Exercise tolerance test was performed on every patient to exclude major ischemia. Echocardiography was performed in left lateral position. Main outcome measure was left ventricular diastolic dysfunction. We enrolled 80 normotensive Type 2 diabetic patients in the study that fulfills the inclusion criteria. Left ventricular diastolic dysfunction was found in 53% [43/80]. There were 20 [47%] males and 23 females [53%] among subjects presenting with diastolic dysfunction. Subjects with diastolic dysfunction the mean age were 55 +/- 15 years. Patients having no left ventricular diastolic dysfunction mean age were 52.5 +/- 7 years. There is a high prevalence of asymptomatic left ventricular diastolic dysfunction in normotensive type 2 diabetic patients

Personality improvement through orthodontics

The aim of this study was to assess and compare changes observed in the weights of patients undergoing fixed orthodontic treatment. These measurements were taken at the start of orthodontic treatment and at two next intratreatment appointments at an interval of one month.This study was conducted on patients who came to Orthodontic Department of Armed Forces Institute of Dentistry [AFID], Rawalpindi. Pretreatment Weight [Wl] of 65 patients was taken before starting the treatment and subsequently [W2 and W3] at the next two intra treatment appointments with an interval of one month. Patients who received fixed orthodontic treatment showed significant weight changes during treatment at Wl, W2 and W3, with a weight loss at W2 and gain at W3 phase level. In all 61. 5% females and 54.6% males reported dietary changes during orthodontic treatment. This indicates that Orthodontic treatment can be used as an adjunctive and preventive measure for weight loss

Frequency of impacted canines in orthodontic patients presenting to armed forces institute of dentistry

The aim of our study was to observe the frequency of patients presenting with impacted canines in our subset of population. This is cross-sectional observational study. The study was conducted in the Orthodontic Department at Armed forces Institute of Dentistry Rawalpindi. Orthopantomographs [OPGs] of 1956 consecutive patients were observed for impacted canines. Thirty two patients were excluded for various reasons. Age and gender was recorded Orthopetomographs [OPGs] and intra-oral photographs were observed to detect the impaction of canines. Out of 1924 orthodontic patients [64] 3.33% were found to have impacted canines. The mean age of the patients presenting with impactions was 18.3 years. The male to female ratio was 1:2. The 87.5% of the impactions were unilateral. Single tooth impactions were the most common followed by two or three impactions in the same patient. The most frequently impacted tooth in 51.56% of the cases was the right maxillary cuspid. The least common was the right mandibular cuspid, 4.7%. A frequency higher than the previously quoted prevalence was found in our study. Racial and ethnic factors may have a role, further large scale studies are required to validate this assumption

Thyroid disorders in Peshawar Pakistan-one year experience

This study reports on 124 cases of thyroid disorders from Peshawar treated with radioiodine during 2008. The aim of this study was to analyze the cancer registry record of patients from the district of Peshawar in order to obtain an insight about thyroid disorders for use in proposrng future health plans. The patient data has been collected from the Institute of Radiotherapy and Nuclear Medicine [IRNUM] Peshawar. Patients with thyroid disorders were confirmed by clinical examination, thyroid scintigraphy [Thyroid scan], blood tests [T[3], T[4], TSH] and histopathalogy tests and then treated with radioiodine. Of all 124 patients with thyroid disorders [Median age; 45.5 years. Range: 16-77 years] 20% were male and 80% were female. The final diagnosis was Toxic Multi Nodular Goiter [TMNG] in 56 [45.1%] cases, Diffuse Toxic Goiter [DTG] in 30 [24.2%] cases, Thyrotoxicosis in 14 [11.3%] cases while 7 [5.7%] patient showed thyroid carcinoma. All these patients were treated with radioiodine. For females, the most affected age group was 11-40 years with 31.3% cases of the total female cases followed by 21-30 age groups. No strict predominance has been observed in any age group of males. This preliminary study will provide an insight to the thyroid disorders and its treatment with radioiodine in Peshawar. Insufficient health care facilities, poor educational market [especially] in the rural areas are the most important probable factors leading to thyroid disorders. This study may be used as a base line for future planning strategies for improving the health standards in Peshawar

Effect of glycaemic status on left ventricular diastolic function in normotensive type 2 diabetic patients

Diabetes is associated with Left ventricular diastolic and systolic dysfunction known as diabetic cardiomyopathy. Echocardiography is helpful for the detection of diastolic dysfunction and echocardiographic screening for asymptomatic diabetic cardiomyopathy should be performed in all asymptomatic diabetic subjects. Identification of diabetic cardiomyopathy should result in the initiation of therapies to prevent the progression of diabetic cardiomyopathy. The objectives of this Descriptive case series was to determine the effect of glycaemic status on left ventricular diastolic function in normotesive type diabetic patients. This study was performed at Cardiology department PGMI Lady Reading Hospital, Peshawar from March 2007 to September 2007. Sixty normotensive type 2 diabetic patients were enrolled, 20 well control, 20 moderately control and 20 poorly control [Group-3]. Main outcome measures was Left ventricular diastolic function determined by Echocardiography. Out of 60 patients there were 32 [53.3%] males and 28 [46.7%] females. Mean E/A ratio in Group 1 was 1.38 +/- 0.29, in Group 2 was 1.16 +/- 0.39 and in Group 3 was 0.60 +/- 0.15 [p<0.05]. IVRT in Group-1 was 91 +/- 7.87 mSec, in Group-2 was 100 +/- 7.83 mSec and in Group-3 was 109 +/- 6.45 mSec [p<0.05]. DT in Group 1 was 207.2 +/- 12.6 mSec, in Group 2 was 218 +/- 11.3 mSec and in Group 3 was 229.7 +/- 9.52 mSec [p<0.05]. Mean Em at mirtal annulus in Group-1 was 0.14 +/- 0.04 m/Sec, in Group-2 was 0.11 +/- 0.04 m/Sec and in Group-3 was 0.10 +/- 0.03 m/Sec [p=0.002]. Left ventricular diastolic dysfunction was documented in 4 [25%] patients in Group-1, 9 [45%] patients in Group- 2 and 16 [80%] patients in Group- 3 [p<0.05]. There was strong correlation between HbA1c level and diastolic indexes [p<0.05]. Diastolic dysfunction is more frequent in poorly controlled diabetic patients and its severity is correlated with glycaemic control

Frequency of anterior bite patients reporting to AFID, Rawalpindi

The purpose of the present study was to calculate the frequency of an anterior open bite in a set of population comprising of military as well as civilian patients reporting to orthodontic department of Armed Forces Institute of Dentistry [AFID], Rawalpindi, from all over the country. Out of a total sample of 1856 patients reporting to AFID from 2001 through 2008, 1800 patients fulfilled the inclusion criteria. Dental records including photographs and casts were assessed for the presence of anterior open bite. The frequency of open bite from the total sample and its percentage with respect to gender and age was calculated. The frequency of open bite was found to be 4%. The mean age of patients was 21.6 years. Females were twice as frequently affected as males. Simple anterior open bite was more prevalent. It is self evident that this is one of the most difficult malocclusions to manage and maintain in orthodontics. Its treatment should be primarily etiology oriented and preferably customized so as to prevent the chances of relapse