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Wear in the upper and lower incisors in relation to incisal and condylar guidance.

The incisors of 85 patients were examined for tooth wear with the aim to evaluate possible association between the degree of wear and anterior guidance. Apart from clinical functional analysis electronic axiography using the system CADIAX was carried out. Anterior guidance in protrusive movement was marked on individually mounted plaster casts and scanned using a pantograph. The cephalometric analysis program CADIAS was used for the metric determination of the anterior guidance angle to the axis-orbital plane, and in order to relate the anterior guidance to the horizontal condylar inclination. The interincisal angle was included in the evaluation as a further functional angle and according to overjet and overbite there were classified typical incisor relations. Where both anterior guidance and incisor inclination and relation were in the normal range, there was an increase in incisal tooth wear in the group investigated. With reduced functional space, frequently found together with anterior deep bite, incisor wear was less extensive. While the occurrence of parafunction was shown not to be related to anterior guidance and incisor inclination and relation parafunctions were the decisive factor in the occurrence of severe incisor wear. Where anterior guidance and incisor inclination and relation are normal, the area of enamel under load is smaller and the space for bruxism larger. Parafunctional forces thus appear to result in a higher degree of wear than is found with the reduced functional space of a steep incisor position. Anterior guidance could not be evaluated as a parafunctonal inducing factor, but only as determining the wear pattern in the individual.

Adult↗

Supine Cephalometric Analyses of an Adjustable Oral Appliance Used in the Treatment of Obstructive Sleep Apnea.

OBJECTIVE: To investigate the effects of the Klearway(TM) appliance on the upper airway in patients with obstructive sleep apnea (OSA) in the supine position. METHODS: Sixteen subjects (12 males and 4 females) were recruited on the basis of baseline polysomnography with a documented Apnea and Hypopnea Index (AHI) >15 per hour. A second overnight sleep study was performed for each subject with the appliance in place. Baseline supine cephalometry was performed for each subject before the initial insertion of the appliance, and follow-up supine cephalometry was undertaken with the appliance in place. RESULTS: The polysomnographic variables improved significantly, and the mean changes in overbite and overjet were 5.15 mm and 6.26 mm after insertion of the Klearway(TM) appliance. The supine sagittal cross-sectional areas of the pharynx and the tongue significantly increased, while the linear distance from the hyoid position to the mandibular plane or the RGN-C3 line significantly decreased after insertion of the appliance. The ratio of the vertical pharyngeal length to the sagittal cross-sectional area of nasopharynx or tongue decreased significantly. When the subjects were evaluated on the basis of the after-insertion AHI, the group with good response (n = 11) was found to be significantly younger than the group with the poor response (n = 5). Similarly, the good responders revealed less prominent chins, larger tongue heights, and an increase in hypopharyngeal sagittal cross-sectional area after insertion of the appliance. There was a significant correlation between the improvement in AHI (%) and the supine middle airway space (r = -0.52, p < 0.05). CONCLUSION: The mechanical effect of the Klearway(TM) appliance on the upper airway and the stabilization of jaw posture may be important determinants of the efficacy of the appliance.

Journal Article↗

Orthodontic space closure without contralateral extraction through mesial movement of lower molars in patients with aplastic lower second premolars.

METHOD AND PATIENTS: A method is presented that allows unilateral space closure in patients with aplastic lower second premolars. Based on a straight-wire appliance, space closure was achieved with a combination of "push mechanics" using the second molar as an anchorage unit and Class II "pull mechanics", thus avoiding the application of any distalizing force on the lower incisors. The results from 13 consecutively treated subjects (five boys, eight girls, mean age 12 years and 6 months) were analyzed. RESULTS: Complete bodily space closure was achieved in all 13 cases within a mean treatment time of 2 years and 7 months. The desired Angle Class III molar relationship of one premolar width (+/- 1/4 premolar width) on the aplastic side was successful in eleven patients, an additional 4.7 mm of space being created for the third molar on the aplastic side compared with the contralateral side (p < or = 0.01). However, adverse effects could be kept to a minimum, with no method-dependent side effects being recorded with regard to canine and molar relationships on the contralateral side, or to overbite, overjet, or upper and lower incisor inclination. The mean lower midline shift of 0.8 mm was in accordance with the mean distal canine relationship of 1/3 premolar width on the aplastic side. CONCLUSION: These results confirm that orthodontic space closure in cases of unilateral aplastic lower second premolars can be performed successfully with the presented treatment method without the need for additional premolar extractions, prosthodontic treatment or implants. Furthermore, the prognosis for the lower wisdom tooth on the aplastic side is improved.

Bicuspid↗

[Midfacial callus distraction in a patient with Crouzon syndrome].

The treatment of syndromic hypoplasias of the midfacial complex, for example in Crouzon patients, is necessary at an early stage for functional and aesthetic reasons. If midfacial advancement is done by the traditional technique using bone grafts, it has often been seen that the normal occlusion originally achieved changes in an Angle class III, because the mandible grows regularly but not the midface. This problem could probably be solved if midfacial advancement is done by the gradual callus-distraction procedure. The local osteogenesis involves the possibility that there is normal growth of the midfacial complex even if the operation is performed in young children. Based on experience in mandibular bone lengthening, this new method was used in a 10-year-old Crouzon patient. As successful lengthening of the midface needs a stable device and a reliable base, a new midfacial distractor was designed using the principle of the halo-frame. With an advancement of about 22 mm the midfacial position was normalized and a regular overbite was achieved. In a case report the new technique is shown and the results are demonstrated and discussed. Despite this encouraging early result a long-term follow-up is not yet possible.

Cephalometry↗

Clinical application and effects of the Forsus spring. A study of a new Herbst hybrid.

BACKGROUND: The best known of the fixed functional appliances are the Herbst appliance and the Jasper Jumper. The Forsus spring is a new development which has been tested in a clinical study to establish when it can be used and to compare it with its predecessors. PATIENTS AND METHOD: The Forsus spring was used over a period of 4 months to treat 13 patients with an average age of 14.2 years with Class II malocclusion. RESULTS: Evaluation of the lateral cephalograms showed that dental effects accounted for 66% of the sagittal correction. The sagittal occlusal relations were improved by approximately 3/4 of a cusp width to the mesial on both the right and left side as a result of distal movement of the upper molars and mesial movement of the lower molars. Retrusion of the upper and protrusion of the lower incisors reduced the overjet by 4.6 mm. Intrusion and protrusion of the lower incisors reduced the overbite by 1.2 mm. The occlusal plane was rotated by 4.2 degrees in clockwise direction as a result of intruding the lower incisors and the upper molars. The maxillary and mandibular arches were expanded at the front and rear during treatment.--Evaluation of a questionnaire filled in by the patients after 2 months of treatment showed that approximately half of them had experienced difficulties in brushing their teeth. The main problem, however, was the restriction experienced in the ability to yawn. Overall, two thirds of the adolescents found the Forsus spring better than the appliance previously used to correct their Class II malocclusion, such as headgear, activator or Class II elastics. CONCLUSION: The Forsus spring has stood the test in clinical application. It is a good supplement to the Class II appliance systems already available.

Adolescent↗

A cephalometric evaluation of the Biobloc technique using matched normative data.

PATIENTS AND METHOD: The outcome of Biobloc treatment was evaluated on 35 patients, 13 male, 22 female, with Class II, Division 1 malocclusions. Cephalometric radiographs were taken before and after treatment. A control group was generated from published normative data in such a way that each treated case was matched individually for age, sex and treatment time. The cephalometric change during treatment was compared to the natural growth change in the matched control group using a Mann-Whitney U-test. The treatment effect was calculated by subtracting the natural growth change from the treatment change. This was then compared to twice the method error to see if the treatment change was clinically significant. RESULTS: There was both a statistically and a clinically significant reduction in overjet (p < 0.001), overbite (p < 0.001) and angle ANB (p < 0.001) with an increase in angle SNB (p < 0.001). None of the other cephalometric parameters measured showed a significant change except for upper incisor proclination (p < 0.05) and ArGoMe angle (p < 0.05) but these were not clinically significant.

Adolescent↗

Effects of angle Class II, division 1 treatment with jumping-the-bite appliances. A longitudinal study.

AIM: The present study investigated treatment effects in patients with Angle Class II, Division 1 malocclusions treated with jumping-the-bite appliances on the basis of cast evaluation and lateral cephalometrics. RESULTS: A significant reduction in overjet (p < 0.001) and overbite (p < 0.01) occurred during the course of treatment. A significant reduction in the SNA-angle (p < 0.001) and increase in the SNB-angle (p < 0.001) led to a reduced ANB-angle (p < 0.001). The treatment effect on the maxilla was greater than on the mandible. A slight posterior rotation of the maxilla (p < 0.05) occurred whereas the other vertical relations did not change significantly. The upper incisors were significantly retruded (p < 0.001) while the lower incisors were increasingly protruded (p < 0.001). The interincisal angle was not markedly altered.

Adolescent↗

Orthodontic space closure without counterbalancing extractions in patients with bilateral aplasia of the lower second premolars.

BACKGROUND: Orthodontic space closure in situations with bilateral aplastic lower second premolars without maxillary extractions is a rarely practiced treatment method. Due to the high risk of severe side effects, preference is currently given to the maintenance of deciduous second molars and subsequent prosthodontic solutions. As a combination of Class I push and Class II pull mechanics seemed likely to reduce secondary effects by transferring the anchorage site from the reactive lower anterior teeth to the more resistant upper arch, a clinical study was carried out in order to investigate effects and secondary effects of the mechanics. PATIENTS AND METHOD: Casts, panoramic radiographs and lateral headfilms of 13 consecutively treated, non-selected adolescents (seven boys, six girls, mean age at start of treatment 13 years 4 months) were evaluated. In six patients a Jasper Jumper trade mark was inserted in addition for a mean period of 6 months. RESULTS: The treatment outcome after a mean period of 3 years and 1 month showed in almost all cases the desired Class III molar occlusion of one cusp width (+/- 1/4 cw) with overbite and overjet within the normal range. Analyses of static and dynamic occlusion revealed anterior/canine protected articulation and a satisfactory number of centric contact points. A significant space gain (p </= 0.01) distal to the lower second molars (right side: 4.9 mm, left side: 5,3 mm) confirmed a relevant movement of the lower molars to mesial and an increased probability of being able to save the lower third molars as a natural substitute for the aplastic second premolars. Mean reductions in incisor inclination were low (0.5 degrees ) in the upper and moderate (4.3 degrees ) in the lower arch. CONCLUSION: Bearing in mind that supporting anchorage measures may be needed to compensate for unfavorable cofactors, the investigated treatment method can be recommended for those patients giving preference to a prosthetic-free dentition and to avoiding surgical interventions.

Adolescent↗

Treatment begin and treatment effect in functional orthodontics with jumping-the-bite appliances.

AIM: The aim of the present study was to investigate the effects of treatment begin in the early and in the late mixed dentition on treatment with jumping-the-bite appliances. PATIENTS AND METHODS: Casts and lateral cephalograms of 69 patients with Angle Class II, Division 1 malocclusions treated with jumping-the-bite appliances were evaluated. RESULTS: A treatment begin in the early or late mixed dentition resulted in a highly significant reduction in overjet and overbite (p < 0.001), in [symbol: see text] SNA and in [symbol: see text] ANB (p < 0.001). An increase of [symbol: see text] SNB depended upon early (p < 0.001) and late (p < 0.01) treatment begin. In the vertical dimension, an early treatment start induced a slightly significant increase in [symbol: see text] NL/NSL and highly significant changes in the upper and lower incisors. With a late treatment start, these changes applied only to the lower incisors. The changes differed significantly only with respect to incisor inclination (upper arch p < 0.01, lower arch p < 0.05). The later the treatment start, the less significant were the dentoalveolar effects. CONCLUSION: At the end of the study period, a slightly significant intergroup difference was recorded for lower incisor inclination only.

Adolescent↗

The Grummons face mask as an early treatment modality within a class III therapy concept.

BACKGROUND AND AIM: An underdeveloped maxillary complex is a major cause of the problems underlying skeletal Class III cases. The efficiency of early orthodontic therapy is shown with reference to a treatment method acting primarily on the maxillary complex. PATIENTS AND METHOD: The collective comprised 21 patients whose orthodontic therapy at the age of 5 to 9 years was invariably started with a palatal expander. This was followed by further development of the nasomaxillary complex, using a Grummons face mask for a period ranging from 3 to 15 months. With reference to findings from plaster casts and lateral cephalograms, the efficiency of early treatment as an important part of the overall therapy concept was evaluated. RESULTS: The mean improvement in anterior overbite was 3.4 mm. The lateral cephalograms revealed a marked improvement in the distance between the upper first molars and the pterygoid vertical (+ 4.1 mm), in the convexity of A (+ 2.2 mm), and in the SNA angle (+ 2.3 degrees). CONCLUSION: Early treatment combining rapid maxillary expansion and Grummons face mask resulted in a decisive improvement in the sagittal-basal relations.

Cephalometry↗

Cephalometric changes following simultaneous first and second maxillary molar distalization using a non-compliance intraoral appliance.

AIM: The aim of this prospective study was to evaluate the dentoalveolar, skeletal and soft tissue changes induced by a modified minimal-compliance intraoral appliance following the simultaneous distalization of first and second maxillary molars. SUBJECTS AND METHODS: The study sample consisted of 14 patients with a mean age of 13.4 years treated by one clinician. In all cases a bilateral Class II molar relationship was corrected to Class I in a mean treatment period of 16.5 weeks. Lateral cephalometric analysis of the sample was based on the radiographs taken before and immediately after treatment with the appliance. The mean maxillary first molar distal movement was 1.4 mm, accompanied by a mean distal tipping of 6.8 degrees. The vertical change in molar position was insignificant. The anchorage unit was unable to completely resist the reciprocal mesial force of the activated coil spring. The second premolars were moved mesially by a mean 2.6 mm and tipped by a mean 4.1 degrees without significant extrusion. The mean increase in overjet was 0.9 mm, and the mean decrease in overbite 1.0 mm. RESULTS: The results of this study have shown that the presented intraoral appliance is an effective and reliable means of distalizing first and second maxillary molars simultaneously without the need for patient compliance. Appliance effects are limited primarily to the dentoalveolar structures. Mesial movement and slight protrusion of the anchorage unit have to be taken seriously into consideration during intraoral distalization.

Activator Appliances↗

Classification of anterior open bite using individualized cephalometry.

OBJECTIVE: The objective of this study was to describe the cephalometric characteristics of the open bite, and to classify the open bite according to individualized norms. MATERIAL AND METHOD: The lateral cephalograms of 134 patients with an anterior open bite (min -0.5 mm) were analyzed. Patients were classified according to the inclination of the jaws, applying the principles of individualized cephalometry. The harmony box described by Hasund was used to define individualized norms for the inclination of the upper and lower jaws in each patient. The open bite was classified into four sub-types: (1) dental, (2) skeletal with enlarged ML-NSL angle, (3) skeletal with reduced ML-NSL angle, and (4) skeletal with deviations in upper and lower jaws. A skeletal open bite was found in 89 patients (66.4%). A dental open bite was found in 45 patients (33.6%). RESULTS: A number of significant differences were found between these four groups using single-factor variance analysis and the Bonferroni a posteriori test, (p < or = 0.05, p < or = 0.01, p < or = 0.001). The most prominent variables were index value of anterior facial hight, total facial height ratio, gonial angle, and Y-axis. No significant differences were found for overbite, however. CONCLUSION: It was possible to use individualized norms to classify the open bite into four sub-types. The demarcation between the four groups was supported statistically. The extent of the anterior open bite does not allow any conclusions as to the craniofacial pattern.

Adolescent↗

Treating Class II patients with removable plates and functional orthopedic appliances-the importance of anterior tooth inclination and direction of growth on treatment outcome.

OBJECTIVE: To determine the influence of physiological growth pattern and anterior tooth inclination on the outcome in Class II patients treated with removable orthodontic plates and functional orthodontic appliances. PATIENTS AND METHODS: After recruiting 50 patients with an upper anterior proclination of 1-SN >or= 107 degrees for this retrospective study, another 50 patients with a retroclination of 1-SN <or= 95 degrees were also included. All patients initially presented a skeletal Class II relationship with a distoclusion of at least one premolar width in the region of the first molars. All patients were evaluated separately by gender and additionally subdivided into three subgroups with a horizontal, neutral, or vertical craniofacial configuration. Treatment with removable orthodontic plates (pretreatment) and functional orthodontic appliances was initiated in mixed dentition. Pre- and post-treatment lateral cephalograms were evaluated for each patient. RESULTS: Dento-alveolar analysis showed that the inclination of the upper incisors changed in the direction of the clinical standard value independent of the craniofacial configuration, although full correction using removable orthodontic plates and functional orthodontic appliances was not always achieved. Similarly good treatment outcomes were achieved with regard to overjet and overbite. The lower incisors of all patients were in proclination after treatment. The ANB angle was reduced in both groups. Nevertheless, on average a skeletal Class II persisted in the Class II, Division 2 patients, while Class II, Division 1 patients with horizontal craniofacial configurations attained skeletal Class I. CONCLUSIONS: Treatment of Class II patients with removable appliances resulted in differences depending on anterior tooth inclination (Class II, Division 1 and II, Division 2) and craniofacial configuration. These differences must be taken into account during treatment planning. Complete treatment success with regard to sagittal jaw balance is very difficult to achieve with removable orthodontic plates (pre-treatment) and functional orthodontic appliances alone in Class II, Division 1 cases with a vertical craniofacial configuration and generally in Class II, Division 2 cases. A particularly favorable constellation for removable treatment is a Class II, Division 1 situation with a horizontal craniofacial configuration and retroclined or orthognathic mandibular anteriors.

Bone Development↗

A premolar extraction case using the Invisalign system.

INTRODUCTION: Invisalign therapy is an orthodontic treatment method using removable transparent polyurethane splints. Its applicability in extraction cases is limited. This case report documents the treatment with Invisalign of a patient in whom four premolars had to be extracted due to dental crowding. FINDINGS AND DIAGNOSIS: The patient's primary objective was to undergo treatment to resolve her anterior crowding as esthetically inconspicuously as possible. Diagnostic findings were: constriction of the maxillary and mandibular arch with anterior dental crowding; proclination and anteposition of the anteriors; neutroclusion with an overjet of 6 mm and an overbite of 1 mm. The radiographs showed a mesial tilt of the lower canines and premolars and a mild skeletal Class II relationship with a vertical craniofacial configuration. TREATMENT PROGRESS AND RESULTS: Treatment was initiated by extracting the four first premolars and placing the attachments (Tetric Ceram composite). After the Invisalign aligners had been worn, the anterior segment was uprighted and retracted, the crowding resolved, and the arches well-aligned. The patient's neutroclusion was maintained, physiological anterior relations in the sagittal and vertical planes were achieved, and the lower canines and premolars were uprighted. Active treatment lasted 1 year and 8 1/2 months and involved 43 maxillary and 28 mandibular aligners. CONCLUSION: Particularly in cases with an extended indication for this new treatment modality, due consideration must be given to the importance of comprehensive and meticulous diagnostics and treatment planning, and a solid grasp of the biological and mechanical fundamentals.

Adult↗

Cephalometrics in children with Down's syndrome.

AIMS: To describe the craniofacial morphology of a group of patients with Down's syndrome using a cephalometric analysis of the lateral skull radiograph. MATERIALS AND METHODS: The studied sample consisted of 39 patients with Down's syndrome (24 boys, 15 girls) ranging from 7 to 18 years of age. The computerized cephalometric study of the lateral skull radiograph of each patient was carried out using the method described by Ricketts. RESULTS: Anterior cross-bite was observed in 38.4% of patients and diminished interincisal angle in 77%. Skeletal parameters matched the clinical norm, indicating mesofacial biotype, i.e., normal maxillomandibular growth. The lower incisors protruded in 84.6% of the individuals studied and were proinclined in 77%; upper incisors were protruded in 77% of the sample. The lower lip protruded in 84.6%. Analysis of craniofacial parameters showed average values within the clinical norm. Analysis of the inner cranium demonstrated normal inclination of the cranial base, while the length of the anterior skull base was diminished in 53.8%. CONCLUSIONS: From the skeletal perspective, patients with Down's syndrome who are in a period of growth demonstrate a reduction of the anterior skull base. From the dentoalveolar perspective, they show protrusion and proinclination of lower incisors, which is related to a tendency to anterior cross-bite and, to a lesser extent, to diminished overbite. Likewise, the lower lip protrusion observed in this study is related to the position of the lower incisor.

Adolescent↗

Review of oral appliances for treatment of sleep-disordered breathing.

Between 1982 and 2006, there were 89 distinct publications dealing with oral appliance therapy involving a total of 3,027 patients, which reported results of sleep studies performed with and without the appliance. These studies, which constitute a very heterogeneous group in terms of methodology and patient population, are reviewed and the results summarized. This review focused on the following outcomes: sleep apnea (i.e. reduction in the apnea/hypopnea index or respiratory disturbance index), ability of oral appliances to reduce snoring, effect of oral appliances on daytime function, comparison of oral appliances with other treatments (continuous positive airway pressure and surgery), side effects, dental changes (overbite and overjet), and long-term compliance. We found that the success rate, defined as the ability of the oral appliances to reduce apnea/hypopnea index to less than 10, is 54%. The response rate, defined as at least 50% reduction in the initial apnea/hypopnea index (although it still remained above 10), is 21%. When only the results of randomized, crossover, placebo-controlled studies are considered, the success and response rates are 50% and 14%, respectively. Snoring was reduced by 45%. In the studies comparing oral appliances to continuous positive airway pressure (CPAP) or to uvulopalatopharyngoplasty (UPPP), an appliance reduced initial AHI by 42%, CPAP reduced it by 75%, and UPPP by 30%. The majority of patients prefer using oral appliance than CPAP. Use of oral appliances improves daytime function somewhat; the Epworth sleepiness score (ESS) dropped from 11.2 to 7.8 in 854 patients. A summary of the follow-up compliance data shows that at 30 months, 56-68% of patients continue to use oral appliance. Side effects are relatively minor but frequent. The most common ones are excessive salivation and teeth discomfort. Efficacy and side effects depend on the type of appliance, degree of protrusion, vertical opening, and other settings. We conclude that oral appliances, although not as effective as CPAP in reducing sleep apnea, snoring, and improving daytime function, have a definite role in the treatment of snoring and sleep apnea.

Continuous Positive Airway Pressure↗

A handicapping malocclusion assessment study at West Virginia University.

1. The AAO Handicapping Malocclusion Assessment Record (HMAR) was tabulated using 100 before-treatment records and dental casts of patients presenting with permanent dentition. 2. The 100-patient sample exhibited scores ranging from 52 points to 11 points. A cut-off point was established at 30 points. This divided the sample into two groups of fifty patients each. This hypothetic situation accepted for treatment those with the fifty highest scores and did not accept those fifty with the lowest scores. 3. The accepted group had 70 per cent skeletal malrelationships (Class II and Class III), while the nonaccepted group presented with 32 per cent skeletal discrepancies. 4. Maxillary incisor interarch deviations were found in 48 per cent of the accepted group but in only 12 per cent of the group not accepted. 5. Mandibular incisor interarch deviation (overbite) occurred in 6 per cent of the nonaccepted group and in 54 per cent of the accepted group of patients. 6. Four patients who required rapid palatal expansion and one who had undergone a mandibular resection were in the nonaccepted group. It was shown that if these patients were examined clinically using the Supplementary Oral Assessment Record, 19 their dentofacial deviations would merit 16 additional points and all five would be promoted to the accepted group.

Child↗

Lower incisor extraction in orthodontic treatment.

The extraction of a single mandibular incisor can be employed as a compromise treatment of certain malocclusions, if the end result fulfills the requirements for a healthier dentition which is functionally and esthetically harmonized in relation to the surrounding structures. Indications, contraindications, and the procedure of treatment have been presented. Class I malocclusions with normal maxillary dentition and good buccal interdigitation in which there is severe lower anterior crowding are the best cases for this procedure, provided that the lower anterior arch length deficiency is greater than 4 to 5 mm. and the anterior tooth ratio is more than 83 mm. In conditions exhibiting a deep overbite pattern, reduction of the mandibular anterior unit should be avoided. Furthermore, I do not regard mandibular incisor extraction as a routine orthodontic procedure but, instead, consider it to be an almost last resort measure since it involves the most important stabilizing area of occlusion.

Adolescent↗