Vol. 32 No. 01 Jan-Mar 2023

Dental awareness has increased in the past few years amongst the Pakistani population. Although it is a major step toward better dental health, many people still only consider filling and tooth pain as dental treatment possibilities. People are slowly but gradually getting more and more awareness about the different fields in dentistry and the existing treatment options. Orthodontics is one such field where a lack of awareness leads to the option of either never getting a treatment or one where the patient reports at a stage where the problem has been complicated by several factors. Awareness about Orthodontics and the different treatment options available for different age groups can easily solve this problem.
There has been a huge increase in the number of orthodontic treatment options and their availability in developed as well as developing nations over the past few decades. It is a well- known fact that patient satisfaction isinfluenced by sex, age,1,2 total treatment time, socioeconomic and financial status, as well as convenience of orthodontic facilities.3-6 Studies have observed and confirmed that girls, on average, receive orthodontic treatment more frequently than boys and that a large number of people undergo orthodontic treatment7 because they were told by a relative or friend that your dental problem can be corrected.
To expect awareness about orthodontics in the general population it is vital to start from the younger generation. Children and teenagers8 are the majority of orthodontic patients.9 Their parents and teachers play a vital role in introducing orthodontic care. Parents and teachers are the most important factor in the motivation for orthodontic treatment. Orthodontic awareness campaigns should be focused on targeting school children. The aim of these campaigns should be to convey knowledge about their occlusion and malocclusion and when should one visit a dentist or an orthodontist concerning a dental issue. School teachers are a group that has a close routine association with these children and teenagers, and they are highly inspired by them.6,8-9 Ehizele et al.10 concluded that teachers may accomplish the function of oral health educators if they have good knowledge, attitude, and practice of oral health; therefore, primary school teachers can help as oral health educators after organized training to expand their understanding of oral health.10 It is thus important to know as to what degree our schoolteachers are aware of the field of orthodontics and how often can we rely upon them to recommend and refer their students to an orthodontist.

METHODOLOGY
This observational study was performed after the ethical approval of institutional review board at Abbottabad International Dental College. The data collection and manuscript writing were done within a period of six months. A questionnaire was converted into online forms (via google forms) and circulated among schoolteachers. The responses received were then compiled into the results of this study. The inclusion criteria were based on schoolteachers of primary (Grade 1-5), middle ( Grade 6-8) and high school (Grade 9-12). Any form missing a response to one or more questions, or any form where more than one option is selected were excluded from the study.

DATA ANALYSIS
A total of One hundred and seventy-five responses were received. Data was analyzed using SPSS version 24. The categorical data like age groups, gender and responses were analyzed. Chi-square test was applied to see association between categorical variables (e.g., groups, age groups, and gender) taking p-value < 0.05 as significant.

RESULTS
Two of the One hundred and seventy-five responses received were rejected due to failure of answering a question. The remaining One hundred and seventy-three responses  were analyzed statistically. The categorical data like age groups, gender and responses are presented in form of frequency (Table-1). Association between categorical

STATISTICAL ANALYSIS
In this study 58(33.5%) subjects were 20-30 years old, 61(35.3%) were 31-40 years old, 46(26.6%) subjects were 41-50 years old, and 8(4.6%) subjects were 51-60 years old. There were only 4(2.3%) male participants and 169(97.7%) female participants. Group-1 (n=50, 28.9%) was comprised  of teachers teaching preschool, primary school i.e., Grade 1-5, group-2 (n= 43 i.e., 24.9%) consisted of teachers involved in teaching to Middle School i.e., Grade 6-8 while grade-3 (n= 80 i.e., 46.2%) consisted of teachers teaching students at high school i.e., grade 9-12. There were 23(13.3%) teachers who had ever taken braces treatment, 166(96.0%) heard
about braces, 97(56.1%) knew that braces treatment is called orthodontics, 104(60.1%) knew that teeth can be moved in bone, 154(89.0%) teachers knew anyone who had used braces and 107(61.8%) knew that braces treatment can be done at any age. A total of 138(79.8%) teachers knew that age is important in beginning braces treatment, 159(91.9%) told that braces treatment is more beneficial at young age and 79(45.7%) teachers were agreed that braces treatment cannot be done at advanced age. There were 166(96.0%) knew that braces treatment is done for straight teeth, 137(79.2%) were agreed that braces treatment is done for cosmetic purpose and according to 149(86.1%) teachers that brace treatment is expensive, 147(85.0%) said braces treatment lasts for years, 99(57.2%) knew anyone whose teeth has gone back after braces treatment, 94(54.3%) told that they or anyone did not get treatment because of expensive and 57(32.9%) teachers knew treatment payment can be done in installments (Table-2,3).
There was significant association between the response of braces treatment is expensive with group-III, know anyone who had braces with group-III and know treatment payment can be done in installments with group-I, p-value < 0.05 (Table-3). Braces treatment is expensive was also significant with 31-40 years old teachers, p-value < 0.05 (Table-2).

DISCUSSION
The study was aimed at finding the level of awareness schoolteachers had about Orthodontic treatment and its timing. Studying the results showed that most of the teachers knew or had known someone who had undergone orthodontic treatment, a favorable point for our study as it shows that Orthodontic awareness indeed is present up to a certain level among the population. This can help with our task of teaching them how to identify orthodontic cases and give a general overview regarding treatment, while encouraging a student or his/her parents to seeks treatment. Although the level of awareness towards what orthodontics is? was found to be sufficient but a major lack of awareness is present towards what the treatment is and how is it achieved? This lack of information can be met by conducting educational seminars and giving presentations at schools. Brochures can also be distributed among teachers for this purpose. Educational seminars and presentations can be given directly to students as well. Ilyas2 and Wang6 concluded that schoolteachers are probably one of the major elements in our society for influencing young students to demand for orthodontic treatment. They also play a pivotal role in their compliance towards the treatment progress by encouraging them every step of the way.
Teachers are mostly aware of the socioeconomic status of their students and can thus help them in asking for affordable treatment options. They will not only be able to encourage their students but can also help them overcome bullying from peers.10
86% of the teachers responded positively to orthodontic treatment being expensive. This can be considered a major disadvantage. Lack of interest in finding out about different treatment modalities can be tied to this perception9. Although some treatment options are indeed expensive not all can be termed the same, and sometimes instead of a comprehensive treatment plan a minor correction is enough to solve an
individual’s malocclusion. Anderson et al concluded that providing adequate knowledge to teachers via different information packages is helpful in creating awareness toward orthodontics and orthodontic treatment options. It can also help with providing treatment at the right time and age.8 The following study did not include teachers from all over Pakistan. Forms were circulated among friends and family members who were teachers or had access to teachers. Requesting individuals to respond to forwarded forms was the hardest part of data collection procedure. Similar studies should be carried out on a wider scale and include teachers from remote areas as well. No conflict of interest is present.

CONCLUSION
The questionnaire assessed the knowledge of schoolteachers regarding orthodontics and orthodontic treatment. The was a lack of sufficient knowledge regarding the treatment method and timing of the treatment while most people only knew that the treatment was expensive but were not aware of the different methods the expenses could be handled in.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Shaw WC. Factors influencing the desire for orthodontic treatment. Eur J Orthod. 1981;3:151-62.

2. Ilyas M , Shaheen A, Amjad S, Zubair T,Tariq A. Comparison of knowledge and perception of orthodontic treatment among dental students and local population. Saudi J Oral Dent Res.2021;6:59-62.
https://doi.org/10.36348/sjodr.2021.v06i01.012

3. Sheikh S, Nene S, Kalia A, Gupta G, Mehta K, Mirdehghan N. Awareness of orthodontic treatment and perceptions of dental attractiveness among school children. Univ Res J Dent 2015;5:63-7.
https://doi.org/10.4103/2249-9725.157727

4. Abeleira MT, Pazos E, Ramos I, Outumuro M, Limeres J, SeoaneRomero J, et al. Orthodontic treatment for disabled children: A survey of parents’ attitudes and overall satisfaction. BMC Oral Health.2014;14:1-8.
https://doi.org/10.1186/1472-6831-14-98

5. Singh H, Munish Reddy C, Khera A, Raghav P, Phull TS, Singh N. Awareness of orthodontic treatment in rural school children of Western Uttar Pradesh (Meerut District). IRJCM. 2016;1:7-12.

6. Wang S, Zhang Y. Relationships among satisfaction, treatment motivation, and expectations in orthodontic patients: A prospective cohort study. Patient Prefer Adherence 2016;10:443-7.
https://doi.org/10.2147/PPA.S101825

7. Rastogi S, Jatti RS, Keluskar KM. Assessment of awareness and social perceptions of orthodontic treatment need in adult age group: A questionnaire study. J Oral Health Community Dent.2014;8:95-100.
https://doi.org/10.5005/johcd-8-2-95

8. Anderson LE, Arruda A, Inglehart MR. Adolescent patients’ treatment motivation and satisfaction with orthodontic treatment. Do possible selves’ matter? Angle Orthod 2009;79:821-7.
https://doi.org/10.2319/120708-613.1

9. Rafighi A, Foroughi Moghaddam S, Alizadeh M, Sharifzadeh H. Awareness of orthodontic treatments among schoolteachers of two cities in Iran. J Dent Res Dent Clin Dent Prospects. 2012;6:25-8.

10. Ehizele A, Chiwuzie J, Ofili A. Oral health knowledge, attitude, and practices among Nigerian primary school teachers. Int J Dent Hyg. 2011;9:254-60.
https://doi.org/10.1111/j.1601-5037.2010.00498.x

Over the past few years, voices have been raised globally to develop standard criteria for dental education and curriculum. Modification in teaching and assessment strategies has been an ongoing process to achieve and improve the set goals. Even the best teaching methods may contain flaws and mistakes. To achieve effective learning, teaching, and training, feedback is one of the most important factors that can bring fruitful outcomes with a positive attitude toward the learner’s behavior.1,2 The effectiveness of the curriculum may be best achieved by student feedback with mental compatibility and understanding between facilitators, learners, and stakeholders.3
A dental student is most likely to learn through an efficient teaching mehodology.4 Adopting an effective learning technique that increases and improves the absorption of a subject is a true learning method.5 Varieties of teaching tools and methods like; Didactic and Interactive lectures, Problembased learning, Process Oriented Guide Inquiry Learning (POGIL), Peer Review, Peer-Led Team Learning (PLTL), Evidence-Based Dentistry, Computer Assisted Learning
(CAL), role play, and models, which are available and is
practiced in many institutes.6
The blended learning technique is a student-centered learning process that promotes and enhances the learning environment by decreasing direct student-to-teacher contact time. However, a study on blended
learning in prosthodontics is still lacking.7
Teaching and training, testing, and examination are crucial to run side by side to develop effective learning dental competencies at the institutional level. Assessment methods should address validity, reliability, acceptance, cost, feasibility, and influence on teaching and learning. MCQs, SEQs, SAQs, OSCE, OSPE, workplace base assessment, Mini-CEX, DOPS, Portfolio, and Viva’s voice are the common assessment tools being practiced in Pakistani institutes.1,8 In most undergraduate dental education systems main focus is  on the development of the contents of the course along with setting the examination pattern for assessment of students’ performance.mPreviously, obtaining feedback from students for their learning improvement was not in focus.9,10 Students are the best judges, who can effectively determine the most appropriate teaching tools and systems. They are in a position to critically assess and logically comment on teaching and evaluation methodology.11,12
The objective of this study was to evaluate the final year BDS students’ perception of prosthodontics as a subject and their feedback on teaching methodologies and assessment tools.

METHODOLOGY
This cross sectional study was conducted in five different dental colleges affiliated with University of Health Sciences, Lahore (UHS). The BDS final year students, (regular batch) who were going to appear for their final university exam having at least 75% attendance were included in the study. Repeaters, detainees and debarred students from the university exam were excluded from study. Sample size calculation was done by using WHO calculator and standard formula (Yates Formula) used was Z= Confidence interval= 95%=1.97 P= Population Proportion= 78%=0.78 d= Margin of error= 5% =0.05
The calculated sample size was 264 students by using 78%15 prevalence of students reported to choose prosthodontics as subject of specialty, 95% confidence interval and 5% margin of error.
A total of 229 final year BDS students of dental colleges affiliated with University of Health Sciences, Lahore participated and responded the survey form questions, with 86.742% participation rate. Data was collected at the end of prosthodontic final year session just before appearing in UHS annual examination 2021 using a predesigned structured questionnaire.13 Electronic informed consent was taken from students prior to data collection. Data was entered and analyzed in SPSS version 25.0. Percentages were used to analyze the data. Percentages and Frequencies were calculated and reported.

The highly reported method useful for learning and understanding prosthodontics was PowerPoint slides 69%, followed by group discussion 52.70%, integrated teaching 38.50%, black board teaching 34.70%, and seminar, the responses in favor of quiz and presentation were 30.10%. (Table 1)
MCQs as mode of assessment was reported in positive by majority of students 75.70%. Students who reported Practical exam, SEQs, VIVA, OSCE and Long essay question answers as the mode of assessment helpful in improving knowledge and application of skills were 61,90%, 59.80%, 45.20%, 42.30%, and 7.10%. (Graph 1)

The knowledge of occlusion is important to an orthodontist for proper finishing of cases to benefit the patients.1 The occlusal plane follows the teeth’s natural curvature forming an imaginary line from incisal
edges of the anterior and occlusal surface of the posterior teeth. Several studies2,3 have described number of occlusal schemes based on scientifically proven evidence and clinical applicability. It is especially true regarding the frontal view of buccolingual posterior cusp as the occlusal surfaces of the molars follow multiple planes.
The height of functional cusp affects the anterior face height. Longer functional palatal cusps and increased buccal inclinations have found to be associated with long lower anterior face height and conversely increased palatal inclination and longer buccal cusps were found in subjects having short lower anterior facial height.4 Andrews5 analyzed a sample of 120 subjects with normal occlusion and derivedsix
keys of occlusion which were used in designing the Straight Wire Appliance. The fourth key of occlusiondescribed Curve of Wilson as a concave curve formed by the angulation of the upper posterior teeth, with molars having lingual crown torque. This curve is considered as a key factor in governing stability aftermaxillary expansion.6 Any alteration in inclination of posterior teeth was considered asone of the most important causative factor in temporomandibular disorders.7
American Board of Orthodontics (ABO) suggested evaluation of differences in buccal and lingual cusps height of the posterior teeth for clinical evaluation of buccolingual inclination. Ideal inclination allows maximum intercuspation and avoids balancing interferences.8 Ross et al9 investigated correlation between inclination of tooth buccolingually and pattern of skeletal growth vertically however insignificant differences were found. Tsunori et al10 (1998) evaluated mandibular first molar inclinations and its relationship to the facial type using CT scans. It was reported by authors that -7° of mean mandibular inclination was found in sample of 21 subjects with dental class I8. Introduction of CBCT to the dental armamentarium has several advantages among
which one of the major advantages is slice by slice mode of imaging. This mode allows tooth to be viewed in different planes11 (Palomo et al, 2006).
Buccolingual inclination of a tooth is important when torque is expressed in a straight wire appliance and successful treatment outcomes and stability are not guaranteed until ideal buccolingual inclinations are expressed for individual patients. In past long axis inclinations of tooth were determined on the basis of crown position however, uneven cuspal wear or tooth morphology may result in uncertainty.
Therefore, using CBCT provides an advantage of visualization of both crown and root. According to pertinent literature survey, no local study has yet reported the buccolingual angulations of mandibular and maxillary first molars in our population. This could help us develop buccolingual prescription for our population.
Therefore, objective of the study was to determine the buccolingual inclinations of mandibular and maxillary first molars in adults using CBCT.

METHODOLOGY
A cross-sectional analytical study was conducted after the exemption taken from the ethical review board (5223-Sur-ERC-18). CBCT images of the patients who have visited dental clinics at AKUH were included in the study. The CBCT was done for routine diagnosis and treatment planning. The sample size was calculated using WHO 7.1 calculator using the findings reported by Alkhatiba12 who reported mean buccolingual inclination of 12.59° and standard deviation of 5.47°. A total of 52 subjects were required to achieve power of 80%, keeping margin of error as 0.05. The non-probability purposive sampling technique was used to obtain data. The subjects in age range of 18 to 65 years with no previous orthodontic therapy, minimum tooth wear, arch length discrepancy of less than 5 mm per arch with no hypodontia other than third molars, were included in the study. Subjects with posterior crossbite, prosthetic crowns or significant fillings on any of the first molars, retained primary teeth and craniofacial deformities were excluded. Using Galaxis/Galileos implant viewer, CBCT images were oriented and standardized. A reference line connecting lower border of mandible was drawn parallel to the floor. In sagittalview, a line was drawn passing through the midpoint of the crown mesiodistally and the mid of both the mid points of each of the mesial and distal roots at one-third the distance from the apex as described by Masumoto et al13 (2001) (Figure 1). Long axis of maxillary molars by connecting a line between furcation and central groove of the molar After achieving sagittal orientation, the angle was

measured from long axis of both maxillary and mandibular molars drawn from transverse view to the true vertical reference line perpendicular to horizontal reference line (Figure 2). Data were collected by the principal investigator (A.Y). The analyses were done using SPSS software for Windows (version 20.0, SPSS). Mean and standard deviations for maxillary and mandibular first molar inclinations were calculated. Frequency and percentages were calculated for  the gender. The comparison of maxillary and mandibular first molars buccolingual inclinations between genders was done using independent sample T test.

RESULTS
There were 52 patients who were included in this study including 30 males and 22 females. The mean age of the sample was 32.2±13.8 years.The mandibular first molars were found to be lingually inclined with mean value of 14.14°±6.33°and 14.00°±5.20° for right and left side, respectively (Table 1).Statistically insignificant differences were found between both the sides. Maxillary first molars were found to be bucally inclined with mean buccolingual inclination of 10.06°±7.31° and 8.79°±8.10° for right and left side, respectively with insignificant differences
(Table 2). Insignificant differences were found in maxillary and mandibular molar inclinations among the genders
(Table 3).
The radiographs were reassessed by the examiner (A.Y) after 3 weeks and intraexaminer reliability was tested using intraclass correlation coefficient and excellent correlation was found between two sets of reading

DISCUSSION
Buccolingual inclination of posterior teeth plays important role in static and functional occlusion. Evaluation can be done clinically by assessing clinical crown and radiographically using CBCT. CBCT images have the advantage of visualizing complete tooth structure i.e. both crown and root. This complete visualization of tooth can help avoiding errors of inclination measurement as on dental cast due to dental wear and morphological uncertainties14,15 although unnecessary radiation exposure requires clinical justification.
Maxillary molar inclinations on CBCT can be difficult to measure due to root divergence. Authors have reported different methods of assessment. Mitra16 measured maxillary molars inclinations by buccal roots only using CT images. Study conducted by Alkhatiba12 measured long axis of maxillary molars by connecting a line between furcation and central groove of the molar,similar method was used in this study.Mandibular molar roots bifurcate anteroposteriorly, therefore long axis can be drawn from central groove to root apex.17
The mandibular first molar in our study showed a mean lingual 14.07° while study by Alkhatiba12 showed a lingual inclination of 12.6°. Ross et al9 reported mean mandibular molars inclination of 7.18° in untreated normal occlusion patients, however the study was performed on dental casts and growing patients were also involved. Tsunori et al10 in their studydetermined mandibular molar angulation of 14.2° ± 3.4and 9.8° ± 4.6in patients with average and short facial heights respectively.
In our study majority of maxillary molars showed buccal inclinations with mean inclination of 9.42° however, Alkhatiba12 reported mean inclination of 4.85°. A study conducted byBarrera et al14 reported4.058° of crown angulation, however this study was conducted on small sample consisting of 10 subjects only. In another study conducted by Ross et al9 found a mean buccal angulation in maxillary molars of 8.08° ± 4.08 in a group of patients aged 9.5 to 41.5 years while using dental casts. Janson et al18compared vertical growth pattern in their study, he found mean buccal inclination for maxillary molars of 5.13° ±4.46 and 7.74° ±4.41 for horizontal and vertical growth patterns respectively. Andrews19 reported maxillary inclination of 11.53° and mandibular inclination,-30°.
Mesiodistal width of posterior teeth has also an important clinical implication when there is discrepancy between tooth size and arch length. Mild to moderate discrepancy can be treated with interproximal stripping or expanding the arch.20,21 In cases with mild to moderate crowding and constricted arch,expansion can be done however, torque control is important to achieve normal buccaolingual inclinations of posterior teeth22 (Adkins, 1972).
Stable occlusion is important for jaw function; additionally it also has an impact on TMJ health and function. Instability in occlusion has short and long term effects on TMJ that may result in asymptomatic click and crepitus to temporomandibular dysfunction disorders. Altered buccolingual inclination results in occlusal interference therefore norms should be established to avoid detrimental effects.

CONCLUSIONS
It can be concluded from this study that maxillary molars are more upright over the basal bone than the mandibular molars. Mean buccal inclination of maxillary molars was found to be 9.42° while mandibular molars had a mean lingual inclination of 14.07°.

CONFLICT OF INTEREST
None to declare

FUNDING DISCLOSURE
None to declare

REFERENCES
1. Mohlin BO, Derweduwen K, Pilley R, Kingdon A, Shaw WC, Kenealy P. Malocclusion and Temporomandibular Disorder: A Comparison of Adolescents with Moderate to Severe Dysfunction with those without Signs and Symptoms of Temporomandibular Disorder and Their Further Development to 30 Years of Age. Angle Orthod. 2004;74:319-27

2. Schuyler C. Correction of occlusion; disharmony of the natural dentition. N Y State Dent J. 1947;13:445-62

3. Beyron H. Optimal occlusion. Dent Clin North Am. 1969;13:537-54.
https://doi.org/10.1016/S0011-8532(22)03363-8

4. SchudyF.Cant of occlusal plane and axial inclinations of teeth. Angle Orthod 1963;33:69-82.

5. Andrews FL. The six Keys to normal Occlusion. Am J Orthod. 1972;62: 296-309.
https://doi.org/10.1016/S0002-9416(72)90268-0

6. Marshall S, Dawson D, Southard KA, Lee AN, Casko JS, Southard TE.Transverse molar movements during growth. Am J Orthod Dentofacial Orthop. 2003;124:615-24.
https://doi.org/10.1016/S0889-5406(03)00630-9

7. Ito H, Okimoto K, Mizumori T, Terada Y, Maruyama T. A clini¬cal study of the Relationship Between Occlusal Curvature and Craniomandibular Disorders. Int J Prosthodont. 1997;10:78-82

8. Casko JS, Vaden JL, Kokich VG, Damone J, James RD, Cangialosi TJ et al. Objective grading system for dental casts and panoramic radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop 1998;114:589-99.
https://doi.org/10.1016/S0889-5406(98)70179-9

9. Ross VA, Issaacson RJ, Germane N, Rubenstein LK. Influence of vertical growth pattern on faciolingualinclinationsand treatment mechanics. Am J Orthod Dentofacial Orthop 1990;98:422-9.
https://doi.org/10.1016/S0889-5406(05)81651-8

10. Tsunori M, Mashita M, Kasai K. Relationship between facial types and tooth and bone characteristics of the mandible obtained by CT scanning. Angle Orthod 1998;68:557-62.

11. Palomo JM, Kau CH, Bahl-Palomo L, Hans MG. Three dimensional cone beam computerized tomography in dentistry. Dent Today 2006;25:130-5.

12. Alkhatiba R, Chungb CH, Buccolingual inclination of first molars in untreated adults:A CBCT study. Angle Orthod. 2017;87:598-602
https://doi.org/10.2319/110116-786.1

13. Masumoto T, Hayashi I, Kawamura A, Tanaka K, Kasai K. Relationships among facial type, buccolingual molar inclination, and cortical bone thickness of the mandible. Eur J Orthod. 2001;23:15-23
https://doi.org/10.1093/ejo/23.1.15

14. Barrera JM, Llamas JM, Espinar E, Sa’enzRam’irez C, Paredes V, P’erez-Varela JC. Wilson maxillary curve analyzed by CBCT. A study on normocclusion and malocclusion individuals. Med Oral Patol Oral
Cir Bucal. 2013;18:547-552.
https://doi.org/10.4317/medoral.18291

15. Shewinvanakitkul W, Hans MG, Narendran S, Martin Palomo J. Measuring buccolingual inclination of mandibular canines and first molars using CBCT. Orthod Craniofac Res. 2011;14:168-74. https://doi.org/10.1111/j.1601-6343.2011.01518.x

16. Mitra S, Ravi MS. Evaluation of buccolingual inclination of posterior teeth in different facial patterns using computed tomography. Ind J Dent Res. 2011;22:376-380.
https://doi.org/10.4103/0970-9290.87056

17. Kasai K, Kawamura A. Correlation between buccolingual inclination and wear of mandibular teeth in ancient and modern Japanese. Arch Oral Biol. 2001;46:269-73
https://doi.org/10.1016/S0003-9969(00)00106-0

18. Janson G, Bombonatti R, Cruz KS, Hassunuma CY, Santro MD. Buccolingual inclinations of posterior teeth in subjects with different facial patterns. Am J Orthod Dentofacial Orthop 125:316-22.
https://doi.org/10.1016/j.ajodo.2003.03.010

19. Andrews LF. Straight Wire: The Concept and the Appliance. San Diego: L.A. Wells; 1989.

20. Sheridan J, Hasting J. Air-rotor stripping and lower incisor extraction treatment. J ClinOrthod 1992;36:18-22.

21. Peck S, Peck H. Crown dimension and mandibular incisor crowding. Angle Orthod 1972;42:148-53

22. Adkins M, Nanda R, Currier G. Arch perimeter changes on rapid palatal expansion. Am J Orthod Dentofacial Orthop 1990;97: 194-9.
https://doi.org/10.1016/S0889-5406(05)80051-4

Sci-Hub is a project that provides free access to scientific articles and journals, particularly those published behind paywalls. The project was created in 2011 by Kazakhstani graduate student Alexandra Elbakyan,
who was frustrated by the excessive cost of accessing scientific articles. Sci-Hub uses stolen log-in credentials to access pay-walled articles, which it then makes available for free on its website.
The impact of Sci-Hub on medical journals has been significant, as it has provided millions of users with free access to articles that would otherwise be unavailable to them. According to a study published in the Journal of the American Medical Association, Sci-Hub had the highest number of downloads for five of the six most accessed journals in the field of medicine, including The New England Journal of Medicine and The Lancet.1
The Higher Education Commission (HEC) of Pakistan is a government agency responsible for promoting research and higher education in Pakistan. One of the ways that the HEC promotes research is by providing access to scientific articles and journals through its online research portal, the HEC Digital Library. The HEC Digital Library provides access to more than 8,000 scientific journals and more than 400,000 articles and is a valuable resource for researchers in Pakistan. However, the HEC Digital Library (http://www.digitallibrary.edu.pk/) is not without limitations, as it only provides access to a limited number of journals and does not cover all research areas. In this context, the Sci-Hub project has emerged as a popular alternative for researchers in Pakistan who are seeking access to scientific articles and journals that are not available through
the HEC Digital Library. Sci-Hub is a project that provides free access to scientific articles and journals, particularly those published behind paywalls. It uses stolen log-in credentials to access paywalled articles, which it then makes available for free on its website.
Although the HEC does not condone the use of Sci-Hub, it has acknowledged that the project has the potential to fill a gap in the availability of research materials for Pakistani researchers. In a statement, the HEC stated that it “appreciates the efforts of Sci-Hub to provide free access to scientific research materials” but cautioned that “the use of Sci-Hub is illegal and could have negative consequences for the scientific community” (Higher Education Commission, 2017).
Most universities in Pakistan rely on HEC for access to scientific journals, and only a few subscribe to limited journals. Most medical and dental journals are beyond the budgets of researchers and academicians, making it difficult or them to access them.
Although some argue that Sci-Hub provides a valuable service by making scientific research more accessible, others argue that it undermines the business model of scientific publishing and could harm the financial viability of medical journals. Many journals rely on subscription fees and payper-view charges to fund their operations. The widespread use of Sci-Hub could reduce its revenue and impact their ability to publish high-quality research.
Some medical journals have responded to the threat of Sci-Hub by increasing their efforts to promote open-access publishing, which allows articles to be freely accessed by anyone with an Internet connection. However, this model has challenges, requiring authors to pay publication fees, and may not be sustainable for all journals. The legality of Sci-Hub, a project that provides free access to scientific articles and journals, has been the subject
of much debate and legal action. Sci-Hub uses stolen login credentials to access paywalled articles, which it then makes available for free on its website.2
In 2015, the American Chemical Society (ACS) filed a lawsuit against Sci-Hub and its founder, Alexandra Elbakyan, alleging copyright infringement and violation of the Computer Fraud and Abuse Act (CFAA) (American Chemical Society v. Sci-Hub, 2017). The ACS argued that Sci-Hub’s actions constituted unauthorized access to its copyrighted material and sought damages of $4.8 million.3
In 2017, a US District Court ruled in favor of ACS and granted an injunction against Sci-Hub, ordering it to stop distributing ACS articles and to give its domain name to the ACS (American Chemical Society v. Sci-Hub, 2017). However, Sci-Hub continues to operate and has remained
active, using a series of new domain names and mirror sites to evade legal action.
The legality of Sci-Hub has also been the subject of debate in other countries. In Russia, where Sci-Hub was founded, the project has faced legal challenges, but has generally been able to operate without interference. In other countries, such as the United Kingdom and Germany, courts have issued injunctions against Sci-Hub and ordered Internet Service Providers (ISPs) to block access to the site. In March 2021, a warning was issued by the City of London Police’s Intellectual Property Crime Unit (PIPCU) to students and universities cautioning them not to use Sci-Hub as it hosts stolen intellectual property. PIPCU warns users of “malicious methods” of obtaining papers, including phishing emails that trick users into providing their university login details.
In this way, Sci-Hub is alleged to have hacked 42 universities. PIPCU has not mentioned the names of these 42 universities, and none of the universities in the UK have ever reported any hacking by Sci-Hub.
The authorities of most countries warn users to stay away from Sci-Hub to protect both their cybersecurity and their institution’s cybersecurity. They also remind users that accessing the site is illegal as the content is stolen intellectual property. Some claim that by downloading articles from
Sci-Hub, malicious software and malware will automatically be downloaded, although most antivirus and antimalware software deem these sites safe for browsing. Some authorities warn that the manuscripts downloaded from Sci-Hub could be truncated and incomplete. Sci-Hub was first sued in 2015 by Elsevier in one of the most important copyright cases of the century. Sci-Hub was found to have infringed Elsevier’s copyright in that case and was fined $15 million. The Sci-Hub domains were blocked by ISPs in Sweden, the United Kingdom, Russia, Belgium, and France following lawsuits in Europe. Libgen and Sci-Hub are also on the European Commission’s piracy watch list. Sci-Hub and Libgen constantly change their URLs to avoid ISP blocking challenges by utilizing ever-shifting domains and untraceable VPN servers. Furthermore,
academicians from developed countries constantly assist Sci-Hub by uploading the latest research publications to strengthen their databases. Libgen and Sci-Hub have now become the Robinhood of Science, stealing manuscripts from wealthy journals, and storing them on public servers for the needy and poor.
Overall, the legality of Sci-Hub is a complex and ongoing issue, with legal challenges and decisions varying by country. While some argue that Sci-Hub provides a valuable service by making scientific research more accessible, others argue that it violates copyright laws and threatens the financial viability of scientific publishers. There are legal ways to access scientific manuscripts, such as using free browser extensions such as CORE discovery, Unpaywall, and Open Access button. The Facebook group “Paper Request” is run by academicians to help researchers gain access to scientific manuscripts. Google Scholar has started compiling all free versions available to any manuscript available to readers through the “All versions” option. Furthermore, there are research platforms like ResearchGate where articles can be downloaded or requested directly from the author. Though they might not be as fast as a Sci-Hub search, these solutions are legal. Researchers are debating whether they should only be able to access scientific information for a fee or whether they should be able to access it free to citizens who pay for it through their taxes.
Publicly funded research is often published in journals that cost thousands of dollars a year to read. This barrier to access excludes poorer institutions, independent researchers, and the general public from the scientific insights “protected” by this very profitable system. Sci-Hub and Libgen provide readers with free access to these resources without commercial interest. Some authors claim that journals charge exorbitantly, although the researcher generates the knowledge, and the reviewers are not paid for the peer-review process. So, it is a case of academic exploitation and restricting research in paywall servers for only the wealthy. The publish-or-perish model of academia sustains large publishing monopolies and their “authority of knowledge.” The pay-for-knowledge model has fueled inequalities
in science and technology. The government needs to address this by negotiating with these academic journals to establish affordable subscriptions throughout the country. Meanwhile, Sci-Hub seems to be the only solution for needy researchers and Libgen for those students who cannot afford books. In general, the Sci-Hub project has significantly impacted research in Pakistan, as it has provided researchers with access to articles and journals that are not available through the HEC Digital Library. While the HEC does not condone the use of Sci-Hub, it has recognized the project’s role in promoting research in the country. Although it can potentially increase the accessibility of scientific research, it also threatens the financial viability of medical journals and could have negative consequences for the scientific community

CONFLICT OF INTEREST
None declared

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