3-Dimensional Evaluation of Two PNAM Techniques (Modified Grayson & AlignerNAM) on Facial Soft Tissue Morphology: A Randomised Clinical Trial.

OBJECTIVE: Evaluate facial changes after Presurgical Naso-Alveolar Molding (PNAM) in unilateral cleft lip and palate (UCLP) patients treated with Modified Grayson Technique and AlignerNAM (with DynaCleft nasal elevator) using a 3D facial scan. DESIGN: Randomised clinical trial. SETTING: Institutional study. Participants: 20 UCLP patients allocated to two groups (10 patients each). INTERVENTIONS: Group A patients underwent PNAM with Modified Grayson Technique and Group B patients underwent AlignerNAM (with DynaCleft nasal elevator). Their 3D facial scans were obtained by using an iOSbased application (Bellus3D FaceApp) mounted on a novel frame. These .stl files were analysed using 3D software (GOM INSPECT) at three-time intervals; before intervention (T0), after intervention (T1) and one month after lip repair surgery (T2). MAIN OUTCOME MEASURE(S): Changes in facial and nasolabial morphology. RESULTS: Both techniques brought significant improvement in the columellar length, nasal tip projection, columella angle, nasal tip angle and a significant reduction in cleft width. At T1, a statistically significant difference in angular and linear measurements was present in both groups. At T2, no statistically significant difference in linear parameters was observed between the two groups except for the outer lateral height of the non-cleft side, basal lateral height of the non-cleft side, and philtrum width. Similar pattern was observed in angular measurements with no statistically significant difference between the two groups except in nasolabial angle, anterior nasal base triangle III, and anterior nasal root triangle. CONCLUSIONS: Aligner NAM and Modified Grayson technique are equally effective PNAM methods with similar clinical results in nasolabial morphology after lip repair surgery.

Nasolabial appearance in unilateral cleft lip and palate patients: A comparison of aesthetics using two scoring systems: A cross-sectional study.

OBJECTIVE: The objective of the study was to assess nasolabial aesthetics in patients with complete unilateral cleft lip, with or without cleft palate (UCL ± P) using two scoring systems. DESIGN: A cross-sectional study conducted in a tertiary care government hospital. PATIENTS: Photographic records of 91 patients with complete UCL ± P from the age group of 5-18 years (mean age = 13.2 ± 3.14 years) were included. METHOD: A panel of three orthodontists with varying experience in cleft management rated nasolabial aesthetics using two scoring systems, that is Asher Mc-Dade index (AMAI) and Cleft Aesthetic Rating Scale (CARS). Intraclass correlation coefficient, Fleiss' kappa and Cronbach's alpha were used to measure the internal consistency amongst three raters and Spearman-Brown formula was used for measuring overall reliability. Time required for assessment of each photograph was compared with ANOVA. RESULTS: Overall, both AMAI and CARS showed high reliability and outcome assessment with good inter-rater reliability and internal consistency, when used independently by orthodontists having varied experience. Statistically significant difference was present in time taken for assessment of nasolabial aesthetics with CARS index (8.75 ± 1.65 seconds) as compared to AMAI (18.62 ± 3.49 seconds). CONCLUSION: Asher Mc-Dade index and CARS are equally reliable and consistent for the assessment of nasolabial aesthetics in patients with UCL ± P. However, considerably less time was taken for the assessment using CARS index as compared to AMAI. The use of CARS index is recommended for the initial assessment and screening of patients by orthodontists using two dimensional photographs.

Comparative evaluation of nasolabial appearance of unilateral cleft lip and palate patients by professional, patient and layperson using 2 aesthetic scoring systems: A cross sectional study.

OBJECTIVE: To compare the perspective of healthcare providers (orthodontists), cleft patients and laypersons in judging nasolabial aesthetics in patients with complete unilateral cleft lip, with or without cleft palate (UCL ± P) using 2 scoring systems. DESIGN: This cross-sectional study was conducted in a tertiary care government hospital. PATIENTS: Photographic records of 100 patients with complete UCL ± P from the age group of 5-18 years (mean age-12.2 ± 3.93 years) were included in this study. METHOD: Photographic records of 100 patients with complete UCL ± P from the age group of 5-18 years were included. A panel of 3 orthodontists, 3 laypersons and 3 cleft patients rated nasolabial aesthetics using 2 scoring systems i.e. Asher-McDade index (AMAI) and Cleft Aesthetic Rating Scale (CARS). Spearman's split-half reliability, Intra-class correlation coefficient and Cronbach's alpha were computed to measure internal consistency and reliability. Inter-panel agreement between pair of groups was determined by means of Spearman correlation coefficient. RESULTS: Estimated reliability of CARS for 3 raters in each panel was in moderate agreement for orthodontists and cleft patients (0.849 and 0.810). Good repeatability and agreement were recorded with moderate to high intra-panel reliability for all parameters of both AMAI and CARS. Overall inter-panel agreement was moderate for both AMAI and CARS. Pair-wise inter-panel agreement showed a moderately positive correlation in both scales (AMAI and CARS) by cleft patients and professionals. CONCLUSION: CARS index can be reliably used for assessment of nasolabial aesthetics by cleft patients, professionals and lay persons on 2D facial photographs. Patients were more critical than clinicians and laypersons using both indices (CARS and AMAI) as they are more self-aware and conscious. Thus, a clear communication between clinician and patient regarding expectations, perception and satisfaction with surgical results is strongly recommended.

A Three-Dimensional Scale for the Qualitative and Quantitative Assessments of Secondary Alveolar Bone Grafting (SABG) in Unilateral Cleft Lip and Palate Patients Using Cone-Beam Computed Tomography (CBCT).

Background The objective of our study was to derive an objective assessment scale for three-dimensional (3D) qualitative and quantitative evaluation of secondary alveolar bone grafting (SABG) using cone-bone computed tomography (CBCT) in patients with unilateral cleft lip and palate (UCLP). Methods CBCT scans for pre- and 3-month post-SABG were reviewed for bone volume, height, width, and density of the bony bridge formed in the cleft defect in 20 patients with UCLP. Basic descriptive and principal component analysis was used to extract the various sub-components of the scale. Spearman's correlation was used to check the validity of the scale, and intra-class coefficient (ICC) and Cronbach's α were calculated to establish the reliability and retest applicability of the scale. Results Each CBCT scan was assessed in five areas: cementoenamel junction (CEJ), root apex, root midpoint, 3 and 6 mm below CEJ, and tabulated in percentiles of 20, 25, 40, 50, 60, and 75 for all the parameters (bone volume, density, and width). These scores were validated when correlated to the scale given by Kamperos et al. Cronbach's α for the domains demonstrated acceptable to excellent internal consistency. The ICC showed good test-retest reliability having a range of scores from 0.89 to 0.94. Conclusion The proposed scale for the 3D assessment of SABG in patients with UCLP provides gradation for the objective assessment of the bony bridge. This gradation enables the qualitative and quantitative assessments of the bony bridge, thus allowing each clinician to judge SABG more conclusively.

A New Frame for Orienting Infants With Cleft Lip and Palate During 3-Dimensional Facial Scanning.

BACKGROUND: Nonradiographic 3-D assessment of soft tissue facial structures is an ideal tool to measure 3-D facial change and smartphone apps like Bellus 3D have brought these technologies to our doorsteps. Although this app works well for adults, it doesn't do so well with infants as their stabilization is difficult thus proper alignment becomes problematic often leading to distortion. This seriously hampers the repeatability and reliability of the whole process. MATERIAL AND METHOD: A stainless steel rod of 150-cm length is curved into a semicircle of a radius of 42.5 cm. Bases are fabricated at both the ends to firmly hold the stand on the table. A Teflon ring of one inch is made for adjusting the diameter of the camera holder. A camera holder is then attached to the Teflon ring. The mobile holder mounted is free to move within the arc. A 3-D facial scan of a single patient was carried out with the camera mounted on the frame and once without the frame. The same was compared using side-by-side comparison and superimposition of the .STL files from the frontal, profile, and worm's eye view. RESULT AND CONCLUSION: It was found that considerable distortion was noted around the nasal and paranasal areas when the scan was performed without the frame as compared to the one that was taken with the frame. This technique avoided distortion and the difficulty in turning the baby's head to record the lateral portion of the face.

A Comparative Evaluation of Surface and Elemental Changes in Stainless Steel and Titanium Orthodontic Mini-screw Implants: A Multi-arm Randomized Control Trial.

OBJECTIVE: The present study aimed to compare and quantify the surface changes seen in two most commonly used orthodontic miniscrew implants (MSI) materials; titanium and stainless steel after their clinical use. METHODS: 40 MSIs (20 titanium and 20 stainless steel) were retrieved from the maxillary arch of 20 subjects (13 females and 7 males) in the age group of 18 - 27 years (mean age=22.4 ± 3.83 years) after their intended use. 40 (20 titanium and 20 stainless steel) asreceived MSIs were used as control. All the MSIs were analyzed under a Scanning Electron Microscope (SEM) for the characterization of their morphological condition (blunting of tip, surface defects and corrosion). Furthermore, Energy Dispersive X-ray (EDX) microanalysis was carried out to study the changes in surface characterization. RESULTS: When imaged using SEM, as-received Titanium and Stainless Steel MSIs demonstrated a relatively smooth surface with no surface defects. However, the retrieved titanium and stainless-steel implants showed increased surface defects (both corrosion and cracks) with the difference being statistically significant. The retrieved Titanium MSIs (115.31±24.38µm) showed 4 times more blunting compared to the retrieved Stainless-steel MSIs (29.74±8.56 µm), with the latter showing 2-3 times more surface corrosion. CONCLUSION: Clinical usage had pronounced effects on both Titanium and Stainless steel MSI alloys in terms of changes in the surface characteristics. While stainless steel MSIs are more susceptible to surface corrosion, Titanium MSIs exhibit greater alterations in the form of tipblunting and cracks in screw threads.

Comparative assessment of facemask therapy with and without skeletal anchorage in growing Class III patients with unilateral cleft lip and palate (UCLP): A single-center, prospective randomized clinical trial.

OBJECTIVE: The purpose of this study was to evaluate the maxillary protraction effect of facemask therapy with and without skeletal anchorage in growing Class III patients with unilateral cleft lip and palate (UCLP). MATERIALS AND METHODS: Thirty patients (aged 9-13 years) with UCLP having a GOSLON score 3 were selected for this prospective clinical study. The patients were allocated into two groups using computer generated random number table. Group I (facemask therapy along with two I shaped miniplates, FM + MP) and Group II (facemask mask along with tooth-anchored appliance, FM). Skeletal and dental parameters were evaluated on pre- and post-treatment lateral cephalograms and pharyngeal airway on cone-beam computed tomography systems (CBCT) for assessment of the treatment changes. RESULTS: Both methods proved to be effective with statistically significant improvements in skeletal and dental parameters (p < .05). Skeletal parameters (e.g., SNA, convexity-point A, ANB) with the FM + MP group showed greater change compared to those with FM group (SNA, 2.56°; convexity-point A, 1.22°; ANB, 0.35°). Significant proclination of maxillary incisors was observed in the FM group as compared to FM + MP group (U1 to NA, 5.4°; 3.37 mm). A statistically significant increase in pharyngeal airway volume was noted in both groups (p < .05). CONCLUSION: While both therapies are effective in protracting the maxilla in growing patients with UCLP, the FM + MP allows for a greater skeletal correction, minimizing the dental side effects seen with FM therapy alone. Thus, FM + MP appears to be a promising adjunct in reducing the severity of Class III skeletal correction needed in patients with cleft lip and palate (CLP).

Effect of Aligning Forces by Two Preadjusted Edgewise Techniques on a Buccally Positioned Maxillary Canine at Varying Vertical Displacements: A Finite Element Study.

Objective: To evaluate the effect of continuous arch and piggyback mechanics in a straight wire appliance (SWA) for the alignment of buccal and variably vertically positioned maxillary canines. Methods: A three-dimensional finite element model with near-normal occlusion and buccal and vertically displaced maxillary canines was used. Two groups were created to simulate two commonly used SWAs techniques, continuous archwire (Group 1) and piggyback models (Group 2). Each group had three subgroups with varying vertical displacement of the canine from 2 to 6 mm from the occlusal plane. The displacement and stress distribution were noted in each group. Results: As the vertical displacement increased in Group 1, the concentration of von Mises stress increased progressively at the incisal third (0.36, 0.41 and 0.44 MPa) at 2, 4, and 6 mm, respectively, with decreased maximum occlusal movement in the vertical plane with respect to the canine. Group 2 exhibited a similar pattern but greater occlusal movement of the canine compared with Group 1. Conclusion: A vertical displacement of 4 mm is the optimal level at which continuous arch mechanics should be considered. For displacements beyond 4 mm, the piggyback wire technique is a suitable alternative.

An assessment of masticatory efficiency and occlusal load distribution in adolescent patients undergoing orthodontic treatment with functional jaw orthopedics: A prospective cohort study.

INTRODUCTION: Functional jaw orthopaedics, produces a radical change in the occlusal scheme and the masticatory apparatus, particularly in patients with Class II malocclusion. It remains to be seen how the changes brought about by a functional appliance alter the masticatory ability of a growing child, who needs the necessary nutrition to properly grow the craniofacial region. MATERIALS AND METHODS: Pretreatment and Post-treatment values of masticatory efficiency and the distribution of the occlusal load at centric occlusion were evaluated and compared for 20 patients with Class II division 1 malocclusion undergoing functional jaw orthopaedics. RESULTS: Significant increase in the masticatory efficiency was seen during and after treatment (p < 0.5) There was an increase in the anterior distribution of occlusal load associated with a concomitant decrease in the posterior region at centric occlusion. CONCLUSION: Improvement in the masticatory efficiency was observed after treatment of a retrognathic mandible with functional jaw orthopaedics in the adolescent participants with Class II malocclusion. This highlights the importance of treatment with functional jaw orthopaedics, which apart from providing esthetic and functional improvement also improves the ability of a growing child to extract proper nutrition from his/her diet.

An arm and a leg: A case of rheumatoid vasculitis and antiphospholipid antibody syndrome.

Rheumatoid vasculitis is a rare extra-articular complication of rheumatoid arthritis. The most common manifestation is cutaneous; however, it can manifest in various organ systems and is associated with a high degree of morbidity and mortality. Diagnosis is challenging, and there are no validated diagnostic or classification criteria. Most cases should be confirmed with tissue biopsy when possible given the severity of disease and the extent of immunosuppression required to treat this condition. We report the case of a 54-year-old white woman with long-standing, uncontrolled, and seropositive rheumatoid arthritis with a history of elevated anticardiolipin IgG and IgM antibodies who presented with acute stenosis of her left femoral artery which ultimately required a left above-the-knee amputation. Histopathology revealed findings consistent with vasculitis and thrombosis, and subsequent imaging revealed multifocal arterial and venous thromboses. She was diagnosed with rheumatoid vasculitis and antiphospholipid antibody syndrome, and was treated with high-dose glucocorticoids, cyclophosphamide, and warfarin. Rheumatoid vasculitis is a rare but devastating complication of rheumatoid arthritis, and vigilance for this condition must be maintained, especially in patients with long-standing, seropositive disease.

Rise and exacerbation of oral lichen planus in the background of SARS-CoV-2 infection.

Oral Lichen Planus (OLP) is a chronic inflammatory disorder whose exact etiology remains unknown. Inflammatory mediators, cytotoxic CD8+ T cells and mast cells have been hypothesized to mediate the pathogenesis of OLP. COVID-19 pandemic caused by SARS-CoV-2 is marked by cytokine storms in the affected patients. Altered T-cell responses marked by exhaustion of T-cell count with hyperaggressive remaining T-cells and presence of cross-reactive antibodies render infected humans as fertile grounds for development of multisystem disorders. In addition, Vitamin D deficiency in COVID-19 patients can further modify the T cell mediated immunity. Increased circulating cytokines and hyperactive CD8+ T cells can alter the oral immune barriers rendering them susceptible to oral disorders. Due to the widespread immune dysregulation, it is possible that patients of COVID-19 may develop OLP in the aftermath or during recovery. The paper explores the pathogenic mechanism behind development OLP as post-COVID condition on account of their target receptor, T-cell responses, cytokine profile, mucosal immune barriers and nutrition deficiency.

Prevalence of species-specific candidiasis and status of oral hygiene and dentition among diabetic patients: A hospital-based study.

OBJECTIVE: The study was undertaken to estimate the species-specific prevalence of oral candidiasis in diabetic individuals in India, and further find the relationship of oral carriage of Candida in diabetes with degree of diabetic control, duration of disease, type of diabetes and its effect on the status of oral hygiene status and decayed, missing and filled teeth (DMFT) score. METHODOLOGY: The prospective cross-sectional study involved 900 individuals (470 diabetic and 430 non-diabetic) visiting a tertiary care hospital. Informed consent was obtained from all the individuals participating in the study. The demographic details, medical history and oral cavity examination were recorded in a specially designed proforma. Swabs were taken for microbiological evaluation for specific prevalence of Candida. RESULTS: The overall prevalence of Candida in diabetics was 22.1% as compared to 9.7% in non-diabetic individuals. However, among the type 1 and type 2 diabetics, the prevalence of Candida was equally distributed as 22.6% and 20.8%, respectively. C. albicans was the most common species (97.1%), while isolated cases of other species like C. rugosa, C. tropicalis, C. glabrata were also observed. The individuals with higher glycaemic score (HbA1c >7) showed higher prevalence of oral candidiasis. Oral hygiene status was observed to be lower among diabetics as compared to non-diabetic individuals. CONCLUSION: Oral candidiasis was more prevalent in diabetic patients, and C. albicans was the most common species. The diabetics also showed higher mean DMFT with lower oral hygiene status as compared to non-diabetic individuals.

Pulmonary epithelioid angiosarcoma responsive to chemotherapy: A case report.

Primary pulmonary epithelioid angiosarcoma (AS) is an extremely rare cancer with a poor prognosis. The presenting symptoms and imaging results are nonspecific and hold similarities with more common lung pathology, contributing to missed or delayed diagnosis. Complementing radiological imaging with patient information, such as presenting symptoms and exposures, is important for early consideration of pulmonary epithelioid AS. Even with supportive imaging findings and clinical suspicion for pulmonary epithelioid AS, the most reliable and definitive method for diagnosis is through immunohistochemistry. We describe the case of a 65-year-old patient who presented with dyspnea, cough, and hemoptysis in whom pauci-immune vasculitis was initially suspected before immunohistochemical diagnosis of primary pulmonary epithelioid AS. Due to the rarity of this disease, treatment options have not been well-studied and consist of any combination of surgical resection, chemotherapy, and radiation therapy. Although typically poorly responsive to chemotherapy, our patient achieved a reduction in size of his pulmonary nodules after a course of steroids followed by cyclophosphamide and was later maintained with gemcitabine and docetaxel until his death nearly a year after presentation.