Comparative analysis of healthcare provision to individuals with cleft lip and/or palate at specialised academic centres in South Africa.

BACKGROUND: Cleft lip and/or palate (CLP) is the most common congenital anomaly of the craniofacial complex, with an estimated worldwide prevalence of 1/500 - 700 live births. Affected children require immediate medical treatment and prolonged management by a multidisciplinary team of health professionals. OBJECTIVES: To describe and compare healthcare provision to individuals with CLP at specialised care centres in South Africa (SA). METHODS: The study was conducted at all CLP care centres in 6 of SA's 9 provinces that provide specialised treatment and care to individuals with CLP. At each centre, the team leader was interviewed using a semi-structured questionnaire that focused on the point-of-care entry for CLP patients; type of services provided; whether treatment protocols were used, which treatment protocols were used and internal referral systems; and members of the healthcare team. Stata 13 (StataCorp., USA) was used to analyse the data. RESULTS: Eleven CLP team leaders participated in the study, of whom 5 were from Gauteng Province. The point-of-care for CLP patients in the majority of centres was plastic surgery (n=9/11; 81.8%). The majority of centres (n=10/11; 90.9%) followed similar treatment protocols and only 1 centre performed lip surgery at 12 - 18 months. Although all centres reported a multidisciplinary team approach for CLP care provision, there were gaps in the health professions categories, which influenced the type of treatment provided. Hence, surgical repair of the lip and palate (n=10/11; 90.9%) and speech therapy (n=7/11; 63.6%) dominated the type of treatment provided, and patients were referred to other provinces or to the private health sector for other types of treatment. CONCLUSIONS: The gaps in services at the CLP care centres in SA need to be addressed to ensure integrated, holistic care provision.

Current ethical issues in HIV/AIDS research and HIV/AIDS care.

HIV/AIDS is a global public health concern with more than 30 million deaths having been reported. Over 70% of the 35 million people with HIV/AIDS live in sub-Saharan Africa. The current available antiretroviral treatments are limited because they do not cure but slow the progression of disease. Therefore, care and treatment for HIV/AIDS and its related research, especially in HIV-preventive vaccine trials, require stringent ethical guidelines because of the vulnerability of the affected individuals as it with all clinical trials. These guidelines should incorporate the basic principles in ethics which include autonomy of individuals, beneficence, non-malfeasance and justice in the care and participation of individuals in research. With at least one in five African adults infected with the disease living in sub-Saharan Africa, this review will discuss the current ethical issues in HIV care and HIV research based on the South African context as well as exploring some of the issues globally.

Application of the dental aesthetic index in the prioritisation of orthodontic service needs.

OBJECTIVE: The provision of orthodontic treatment to patients in government funded training institutions is a major challenge due to constrained budget and resource allocation. The Dental Aesthetic Index (DAI) has been used to estimate orthodontic treatment need and as a screening tool to determine treatment priority. The DAI focuses on aesthetics and therefore omits other malocclusion traits that might require orthodontic treatment. The aim of the study was to compare the application of the DAI with the influence other malocclusion traits not included in the DAI might have on the determination of the prioritisation of orthodontic service need. METHODS: Hundred-and-twenty pretreatment study models of orthodontic patients in the permanent dentition stage were selected from the archived records of the Department of Orthodontics, University of Limpopo, using a systematic sampling method. The study casts were assessed using the DAI. Other malocclusion traits not included in the DAI were also recorded. Descriptive statistics, the Pearson correlation coefficient, Chi-square values and t-tests were employed to analyse the data. P values less than or equal to 0,05 were considered statistically significant. RESULTS: The mean DAI score was 35.2. Normal or minor malocclusion was found in 19.1% of the sample, whilst 17.5% had definitive malocclusion, 21.7% severe malocclusion, and 41.7% showed handicapping malocclusion. Other malocclusion traits not included in the DAI were identified and these traits accounted for 21.6% of all traits recorded in the study (DAI malocclusion traits accounted for 78.4%). Two thirds of other malocclusion traits were accounted for in categories which the DAI had already prioritised for treatment. CONCLUSIONS: The study showed that the DAI can be used to prioritise orthodontic service needs and could be applied in government funded institutions.

Bolton ratios in a sample of black South Africans.

One of the many factors inherent in a good occlusion is the balanced proportionality in the sizes of the upper and lower teeth. Disproportion in the size of individual teeth may result in a malocclusion related to this discrepancy. It is therefore important in diagnosis and treatment planning to determine the amount and location of any tooth-size discrepancies that may exist. Bolton in 1958 developed two equations to calculate the mesio-distal crown size ratios between permanent maxillary and mandibular teeth. Bolton's anterior and overall ratios were 77.2% (SD +/- 1.65) and 91.3% (SD +/- 1.91) respectively. These ratios were used to identify areas of space deficiency or excess in the maxillary and mandibular arches. Individual teeth may differ in size in relation to gender and population groups; Blacks, for example, having generally larger teeth than Caucasians. The purpose of this study was to obtain measurements from a sample of Black South Africans and to compare the ratios derived from these when using the method described by Bolton, with those measurements that were obtained in Bolton's study of 55 Caucasian subjects having ideal occlusion. One hundred study models with excellent occlusion, were selected from the archives of patient records of the Department of Orthodontics, Medunsa Oral Health Centre, University of Limpopo. An equal number of males and females were selected. The anterior and overall tooth-width ratios were calculated from the data of this sample. The ratios obtained for the male and female groups did not differ significantly, although the teeth of males were significantly larger than those of the females. The anterior ratio was found to be 77.26% (SD +/- 2.65), equivalent to Bolton's anterior ratio of 77.2% (SD +/- 1.65), whereas the overall ratio was 92.31% (SD +/- 2), significantly larger than Bolton's overall ratio of 91.3% (SD +/- 1.91). The results indicate that the anterior ratio may be particularly useful when assessing and planning aesthetic alignment of the anterior segment. The overall ratio may be considered less clinically significant and its use in orthodontic treatment planning may require further investigation using the peer assessment rating.

Is orthodontics an option in the management of bimaxillary protrusion?

Successful orthodontic treatment is based on a clear perception by the clinician of a patient's facial preference and treatment needs. Bimaxillary protrusion is a normal facial trait seen in the Black population and the most acceptable bimaxillary facial profile in a sample of Black subjects was determined by Beukes et al in 2007. Variations from this ideal profile may require extractions as part of orthodontic treatment in order to attain the ideal. The objective of this study was to determine whether Black subjects with bimaxillary protrusion would want to change their facial profile to the ideal and at what financial cost. A sample of 586 school learners and 321 university students were presented with four silhouetted profiles of varying degrees of bimaxillary protrusion. One of the silhouette profiles represented the ideal and treatment procedures required to achieve this ideal were explained to the sample. They were then requested to answer a questionnaire that would assist in identifying their perception of their own profile and their desire to change their appearance. The ideal silhouette was confirmed to be the most attractive (91.51%) and the sample felt that any severe deviations from this ideal profile should be treated. The financial cost of treatment was found to be a concern, as more subjects (62.84%) would undergo the required treatment if it were free. Many subjects (43.55%) would be prepared to pay for the necessary treatment to achieve the ideal profile. Females were found to be more definite in their decision making, reflecting a greater awareness about their aesthetic appearance than their male counterparts. Findings from this study can serve as an essential tool to assist both orthodontists and maxillofacial surgeons in the treatment planning and management of Black patients with bimaxillary protrusion.

Shear bond strength comparison of RelyX Unicem with six other orthodontic resin adhesive systems.

Orthodontic bracket adhesion involves multistep procedures which are technique sensitive to various factors within the oral environment. RelyX Unicem is a restorative/prosthodontic adhesive material which by virtue of its one step adhesion procedure may prove to be suitable for efficient orthodontic bonding. The objective of this study was to compare the SBS of RelyX Unicem with six other known orthodontic bonding materials. Seventy extracted human premolar teeth were divided into seven groups of 10 teeth each. On each group, metal orthodontic brackets were bonded using one of the seven bonding materials: (A) Transbond XT primer and Transbond XT luting cement (B) F2000 compomer primer/adhesive (C) Transbond Plus and Transbond XT luting cement (D) RelyX Unicem (E) Prime & Bond NT and Calibra cement (F) Xeno III and Calibra cement (G) NRC + Prime & Bond NT and Calibra cement. Shear bond strength evaluation of each tooth was tested and recorded using the Instron materials testing machine. The results show that the mean SBS for RelyX Unicem is 5.38 MPa and NRC is 4.70 MPa which rates weak compared to all the other materials where the means for the SBS are within the acceptable range of 5.9 to 7.8 MPa. It appears that by reducing the number steps followed for orthodontic bracket adhesion, the SBS of the orthodontic adhesive materials becomes significantly compromised to the extent where such materials can be rejected as suitable for orthodontic bracket adhesion. RelyX Unicem and NRC were found to be unsuitable for orthodontic bracket adhesion.

The repositioning Nance appliance: a fixed functional appliance and case report.

Functional appliances are primarily orthopaedic tools used to influence the facial skeleton in a growing child. These appliances may be fixed or removable. A fixed functional appliance referred to as the Repositioning Nance Appliance (RNA) was developed and a case report is presented. The RNA is a fixed functional appliance consisting of bands on the upper first molars joined together with a 0.036-inch stainless steel wire that is bent around the anterior contour of the palate. Just lingual to the upper incisors the wire is complemented with an acrylic Nance button, which is modified with a downward and backward incline projection. The labial aspect of this projection is smooth and when the lower incisors come into contact with it, they are directed into an edge-to-edge relation with the upper incisors, brought about by forward positioning of the mandible. This has the net effect of relocating the mandible into a Class I relation. A 14-year-old boy in his late mixed dentition stage of dental development presented with mild crowding, a horizontal growth pattern and a skeletal Class II jaw relation caused by an underdevelopment of the mandible. Treatment was initiated using the RNA and continued for a period of 18 months. This was followed by full fixed appliances for another 12 months and resulted in Class I skeletal and dental relations, a reduced overjet and an improved facial profile. The RNA, if applied correctly is a simple fixed functional appliance that can be used with confidence, comfort and economy to both the patient and orthodontic practitioner.

Early orthodontic management of Crouzon Syndrome: a case report.

Crouzon Syndrome is an autosomal dominant disorder with complete penetrance and variable expressivity. Described by a French neurosurgeon in 1912, it is a rare genetic disorder. Crouzon syndrome is caused by mutation in the fibroblast growth factor receptor 2 (FGFR2) gene. The disease is characterized by premature synostosis of coronal and sagittal sutures which begins in the first year of life. Once the sutures become closed, growth potential to those sutures is restricted. However, multiple sutural synostoses frequently extend to premature fusion of skull base causing midfacial hypoplasia, shallow orbit, maxillary hypoplasia and occasional upper airway obstruction.The case of a 7-year-old South African black boy with Crouzon Syndrome is presented. He presented with characteristic triad of cranial deformity, maxillary hypoplasia and exophthalmos. The clinical, cephalometric features and initial orthodontic management of this patient are discussed as part of multidisciplinary management.

Non-surgical treatment of anterior open bite and its assessment using the Dawjee analysis: a case report.

Anterior open bite (AOB) is a dentofacial problem occurring more commonly in race groups of African origin. Although multi-factorial, the aetiology exerts its influence in tandem with craniofacial development. Diagnosis is confirmed by a cephalometric assessment and points either to a skeletal origin, a dental source, or both. Depending on the time of diagnosis and severity of the condition, treatment can vary from interceptive procedures, orthodontics only, or a combination of orthodontic treatment and orthognathic surgery. A case study is presented of an adult female with AOB who was treated nonsurgically. The diagnosis, treatment technique and outcome are described, as well as a pre- and post-treatment evaluation of the cephalograms using the Dawjee analysis. Comparison of pre- and post-treatment cephalometric values show a definite dentofacial improvement, and identifies specific morphologic areas that have changed as a result of treatment. Transformations in anteroposterior maxillary and mandibular positions and orientation are readily detectable, as well as a repositioning of the alveolar processes. While pre and post treatment cephalometric values presented for this patient compare well, these values are case specific and cannot be implemented widely unless the analysis is applied to a larger and more representative population sample and standardised measurements have been established.

Tooth width predictions in a sample of Black South Africans.

Space analysis during the mixed dentition requires prediction of the mesiodistal widths of the unerupted permanent canines and premolars and prediction tables and equations may be used for this purpose. The Tanaka and Johnston prediction equations, which were derived from a North American White sample, is one example which is widely used. This prediction equation may be inapplicable to other race groups due to racial tooth size variability. Therefore the purpose of this study was to derive prediction equations that would be applicable to Black South African subjects. One hundred and ten pre-treatment study casts of Black South African subjects were analysed from the Department of Orthodontics' records at the University of Limpopo. The sample was equally divided by gender with all subjects having Class I molar relationship and relatively well aligned teeth. The mesiodistal widths of the maxillary and mandibular canines and premolars were measured with a digital vernier calliper and compared with the measurements predicted with the Tanaka and Johnston equations. The relationship between the measured and predicted values were analysed by correlation and regression analyses. The results indicated that the Tanaka and Johnston prediction equations were not fully applicable to the Black South African sample. The equations tended to underpredict the male sample, while slight overprediction was observed in the female sample. Therefore, new equations were formulated and proposed that would be accurate for Black subjects.

Facial profile perceptions in a group of South African blacks.

INTRODUCTION: Each society has its own general perceptions of facial aesthetics and one study show that there is significant agreement among populations regarding facial preferences. People of African decent generally have a bimaxillary protrusive profile which in some orthodontic circles is regarded as a malocclusion that should be treated. OBJECTIVES: The purpose of the study was to evaluate Black South African student perceptions on the facial profile of Black South African subjects with bimaxillary protrusion. METHODS: Silhouetted lateral facial profiles of 30 Black South Africans with bimaxillary dento-alveolar protrusion were subjected to an initial evaluation process by 128 students extracted from secondary schools, junior tertiary and senior tertiary university institutions. These evaluators were asked to select the 5 most attractive and 5 most unattractive profiles. Due to a tied ranking 13 instead of 10 of the 30 profiles were selected. The 13 selected profiles were subjected to further evaluation by a group of 605 evaluators from the same educational institutions that had to select five profiles in the categories of the most attractive, attractive, average, unattractive and most unattractive profile. The results were subjected to pairwise comparisons with a Fisher extact test and Z-test for normal approximation of the binomial distribution. RESULTS: From the first evaluation process the average age and gender distribution for the evaluators were 21.8 yrs (75 females and 51 males). The most attractive profiles chosen were nos. 27 (12.19%), 11 (6.88%), 13 (6.88%) and 8 (6.56%). Profiles nos. 2, 12 and 14 (6.25%) were chosen in equal frequency as the fifth most attractive profile. The most unattractive profiles were nos. 18 (9.38%), 29 (8.91%), 22 (7.81%), 30 (7.34%), 6 (6.56%) and 7 (6.56%). The second evaluation process had an age and gender distribution of 21.6 yrs (307 females and 275 males). Profiles no. 1 was chosen as the most attractive, no. 11 as attractive, no. 5 as average and no.6 as unattractive and most unattractive. There was no statistical significant difference between male and female profile preferences. There was a highly statistical significant difference for the most attractive and most unattractive profile. A statistical significant difference was also found between the scholars and the senior tertiary university students in the category of the most unattractive profiles. CONCLUSION: Profile no. 1 was chosen as the most attractive profile. Results indicate that Black South Africans from this sample prefer exaggerated bimaxillary protrusive profiles with lip competence and normal overjet/overbite relationships.

Soft tissue profile analysis in a sample of South African Blacks with bimaxillary protrusion.

INTRODUCTION: Evaluation of facial proportions and shape is one of the most important steps in determining treatment options and outcomes for the orthodontist and maxillo-facial surgeon. Balancing the position of the lips in relation to the nose and chin has a direct relationship with the patient's aesthetic preference. OBJECTIVES: The purpose of this study was to analyse the soft tissue profile preferences in a sample of South African Blacks and to establish a Profile Index for bimaxillary protrusion. METHODS: An earlier study by Beukes, Dawjee and Hlongwa was undertaken to determine facial profile perceptions by a group of South African Black evaluators. Adjudicators were drawn from Black students from Medunsa campus, University of Limpopo, the Holy Trinity secondary school and the Mphwe secondary school, and had to evaluate silhouetted facial profiles of 30 bimaxillary dento-alveolar protrusive patients. After an initial group of 128 Black evaluator chose 13 profiles as the most attractive and most unattractive, a second group of 605 Black evaluators (also drawn from the same academic institutions) chose three profiles as acceptable and four profiles as unacceptable. From this final selection, a soft tissue analysis was undertaken to evaluate the nasolabial angle, nasofacial angle, the facial contour angle, the lower lip-chin-throat angle and the lower and upper lip prominence in relation to the Burstone "B"- line. A Fisher exact test was done to determine the statistical difference between the mean values for the acceptable and unacceptable profiles. RESULTS: The three acceptable profiles, which were chosen by more than 69% of the evaluators, had a lip prominence of 5 to 6mm more than their African American counterparts. The angular measurements of the nose, lip and chin were in close proximity to the values given by Naidoo and Miles and Flynn et al. The three acceptable profiles had normal overjet, overbite, minimal incisor visibility and efficient lip function. CONCLUSION: A "Profile index for bimaxillary protrusion" has been concluded from this study and proposes acceptable soft tissue values for bimaxillary protrusive Black South Africans.

Digital macro-photogrammetry in orthodontic tooth movement: case report.

Digital macro-photogrammetry (DMP) method was used to assess the 3-dimensional (3D) movement of the canine during retraction with a Hybrid Retractor (HR) spring (Forestadent, Pforzheim, Germany) following extraction of first premolars. Computer images of the canine were generated from multiple synchronous digital photos of a patient taken during clinical follow-ups. Time intervals were recorded from the begining of the treatment before the insertion of the spring (T0), to the last follow-up session of canine retraction (T8). All movements of the canine were calculated from the generated three dimensional co-ordinates (X,Y, & Z). The results indicated that the canine was distalized about 6,78 mm over a period of 258 days. The maximum velocity of the canine movement was found to be approximately 1 mm/month. In conclusion, it was found that DMP can be applied in clinical orthodontics to monitor orthodontic tooth movement. This technique is cost-effective and measurements can be made on site as the use of computers and digital photographs have been incorporated in the majority of orthodontic practices.

An introductory report on a new cephalometric method: the Dawjee analysis.

A new method of lateral cephalometric analysis referred to as the Dawjee analysis is introduced. Landmarks, planes and angles are defined, and the technique is outlined. The Dawjee analysis is primarily focused on evaluating craniofacial structures in the vertical dimension and this introductory presentation demonstrates its application in both open and deep bite cases. Studies are in progress to develop a set of standardised values for this technique in a South African population sample.

Malocclusion among 12-year-old school children in Mankweng, Limpopo Province of South Africa.

Consent was obtained from all relevant authorities to undertake an epidemiological survey to determine the occlusal status of a sample of 12-year-old Black school children in Mankweng Circuit, Limpopo Province. The examination was carried out using the Dental Aesthetic Index (DAI) criteria, under conditions prescribed by the WHO in 1987. The results were analysed using the Kotmogorov-Smirnov Test. The results of the study showed that forty seven percent (47%) of the subjects required orthodontic treatment, in the categories: definitive 20%, severe 13% and handicapping 14%. There is a proven need for orthodontic treatment among 12-year-old Black school children in Mankweng. Since there is no government hospital or clinic to provide such treatment, a centre should be established.

Orthodontic treatment needs: comparison of two indices.

The Index of Orthodontic Treatment Needs (IOTN) and the Dental Aesthetic Index (DAI) were developed and both claimed to contain the aesthetic and dental components in their criteria of assessing malocclusion. This study was undertaken to assess the reliability of these two indices in assessing orthodontic treatment needs. The indices were applied to 120 pre-treatment study models selected from orthodontic patient records treated at the Department of Orthodontics, University of North Carolina, United States of America. The sample consisted of 60 African-Americans (Black) and 60 American Caucasians (White), age ranged from 12 to 16 years (Mean 13.8). The results showed that the IOTN and the DAI were highly correlated and highly associated statistically (p < 0.0001). The findings of this study indicated that the two indices could be used consistently to identify orthodontic treatment needs in different ethnic groups and are capable of classifying the subjects according to their malocclusion severity for those subjects eligible for treatment in fund constrained situation.