Evaluation of Quantitative Aspects of Craniofacial Deformities in Transfusion Dependent Beta-Thalassemia Major Patients: A Cephalometric Study.

PURPOSE: To evaluate the quantitative (cephalometric) aspects of the craniofacial deformities in transfusion-dependent beta-thalassemia (TDT) patients. MATERIALS AND METHODS: Sixty-five TDT patients receiving a regular blood transfusion in the Department of Pediatrics of age group 5 to 8 years (younger) and 15 years and above (older) were compared with control groups of similar age using cephalograms (lateral and posterior-anterior view). RESULTS AND OBSERVATION: The prevalence of skeletal class II tendency is higher in thalassemic patients that do not improve with age. The thalassemic patients were found to show large angle ANB i.e. Angle between points point a, nasion and point B (ANB), large flexure angle, small angle SNB i.e. Angle between points sella, nasion and point B (SNB), and normal angle SNA i.e. Angle between points sella, nasion and point A (SNA) angles suggestive of retrognathic mandible. The thalassemic patients were observed to have smaller transverse widths and thickened calvarium on the posterior-anterior view. CONCLUSION: The skeletal class II malocclusion appears to be a manifestation of generalized growth retardation/delayed puberty in thalassemic patients leading to diminished mandibular growth, rather than maxillary prognathism due to marrow hyperplasia.

Efficacy of resin-modified glass ionomer cement varnish in the prevention of white spot lesions during comprehensive orthodontic treatment: a split-mouth study.

OBJECTIVE: To evaluate the efficacy of resin-modified glass ionomer cement varnish in the prevention of white spot lesions (WSLs) during early orthodontic treatment with fixed appliances. MATERIALS AND METHODS: A total of 480 maxillary and mandibular anterior teeth were studied. The varnish was applied to either the right or left side of the maxillary or mandibular anterior teeth on a random basis. For each experimental quadrant in each patient, the varnish was applied to the labial surfaces of incisors and canines, from the gingival surface of the bracket to the free gingival margin. White spot lesions were recorded on a standard pro forma before (T(0)) and approximately 6 months following varnish application (T(1)) by DIAGNOdent and direct visual inspection. RESULTS: The DIAGNOdent score at T(1) was increased significantly in the control maxillary lateral and mandibular central (P < 0·05), and lateral incisors (P < 0·01). The visual scores in experimental maxillary lateral incisors and mandibular canines were decreased significantly at T(1) (P < 0·05). The sidewise post-treatment (T(1)) comparisons of control and experimental teeth for visual scores revealed significant decreases for maxillary lateral incisors, maxillary canines and mandibular canines (P < 0·05). CONCLUSION: Application of resin-modified glass ionomer cement varnish had a favourable effect in the prevention of WSLs during comprehensive orthodontic treatment.

Maxillary distraction osteogenesis at Le Fort-I level induces bone apposition at infraorbital rim.

OBJECTIVE: The aim of this study is to evaluate whether there is any remodeling of bone at infraorbital rim following maxillary distraction osteogenesis (DO) at Le Fort-I level. MATERIALS AND METHODS: Twelve adult subjects in the age range of 17-21 years with complete unilateral cleft lip and palate underwent advancement of the maxilla by DO. The effect of maxillary DO on the infraorbital rim remodeling was evaluated from lateral cephalograms recorded prior to the DO (T0), at the end of DO (T1), and at least 2-years after the DO (T2) by Walker's analysis. The ANOVA and two-tailed t test were used and probability value (P value) 0.05 was considered as statistically significant level. RESULTS: There was anterior movement of maxilla by 9.22 ± 3.27 mm and 7.67 ± 3.99 mm at the end of immediate (T1) and long-term (T2) follow-up of maxillary DO, respectively. The Walker's analysis showed 1.49 ± 1.22 mm and 2.31 ± 1.81 mm anterior movement of the infraorbital margin (Orbitale point) at the end of T1 and T2, respectively (P < 0.01). This apposition of bone at the infraorbital rim region further improved the facial profile of these patients. CONCLUSION: The advancement of maxilla by distraction osteogenesis at Le Fort-I level induced significant bone apposition at infraorbital rim. CLINICAL RELEVANCE: Patients with mild midface hypoplasia who would otherwise may be candidates for osteotomy at Le Fort-II or Le Fort-III level may benefit from maxillary distraction at Le Fort-I level.

Increase in sagittal depth of the bony nasopharynx following maxillary protraction in patients with unilateral cleft lip and palate.

Objective : To study the change in the sagittal depth of the bony nasopharynx in patients with unilateral cleft lip and palate (UCLP), following maxillary protraction using reverse headgear. Methods : Nineteen patients (14 male, five female; aged 9.36 ± 2.89 years) with repaired complete UCLP underwent maxillary protraction with a Delaire type reverse headgear at a tertiary-care referral teaching hospital. Control data were taken from five patients (four male, one female; aged 8.25 ± 2.25 years) who did not receive any orthopedic/orthodontic treatment for a similar duration of time as the treated patients. Average treatment/observation period was 11.71 ± 3.39 months for the treated patients and 12.40 ± 2.60 months for the untreated subjects. Changes in the sagittal bony nasopharynx depth were measured by comparing pretreatment (T1) and posttreatment (T2) lateral cephalograms. Correlations between the changes in the bony nasopharynx depth and in other variables measured in the treated patients were analyzed. An exploratory analysis of differences in the changes from T1 to T2 between the treated patients and untreated subjects was also conducted. Results : The favorable skeletal changes seen in SNA and ANB following maxillary protraction were accompanied by a significant increase in the sagittal depth of bony nasopharynx (1.74 ± 1.10 mm; P < .001). This change was significant when compared with the data from the untreated subjects (P = .004). Correlations between the increase in bony nasopharynx depth and changes in other variables studied in the treated patients were weak and not statistically significant. Conclusion : Sagittal depth of the bony nasopharynx in patients with repaired UCLP increased following maxillary protraction therapy using reverse headgear.

Midsymphyseal distraction osteogenesis with lingual tooth-supported distractor: a case report.

This report presents the treatment of a patient with severe mandibular anterior crowding caused by anterior transverse deficiency of the mandible. The treatment plan called for midsymphyseal distraction osteogenesis. A tooth-supported distractor placed on the lingual aspect of the mandible was used for mandibular widening.

Arrowhead elastic for simultaneous correction of overjet and overbite.

Arrowhead elastic may be integrated with fixed appliances to achieve rapid correction of increased overjet and overbite during comprehensive orthodontic treatment. This technique is applicable in routine class II cases involving deep bite, during retention phase in growing children treated with twin block and postsurgically in adult hypodivergent cases.

Craniofacial computerized tomography analysis of the midface of patients with repaired complete unilateral cleft lip and palate.

INTRODUCTION: Computerized tomography (CT) makes regional anatomy available as a series of cross-sectional axial images that can be analyzed unobstructed by other anatomic features. In this study, we aimed to analyze the maxillary dentoalveolar and deeper structures in patients with surgically repaired complete unilateral cleft lip and palate (CLP) and to investigate whether significant asymmetry existed in the deeper midfacial structures, using axial CT. METHODS: Axial CT scans of 15 children (7 boys, 8 girls; mean age, 11.59 +/- 1.34 years) with repaired complete unilateral CLP were acquired parallel to Reid's base line. Specific landmarks applicable for CT were defined and plotted to undertake a comprehensive Craniofacial CT Analysis of the midface. Twenty-six pairs of transverse and sagittal measurements made to a cranial base midsagittal construct and interspinosum fit line, respectively, were compared by using the paired t test. RESULTS: Significant reduction of 19.05% in the nasal chamber width (2.54 +/- 1.49 mm; P <0.001), more distal position of the bony alar base (2.28 +/- 1.71 mm; P <0.001), and the sagittal position of the most prominent anterolateral point on the maxillary alveolar process (1.62 +/- 1.85 mm; P <0.01) were noted on the cleft side. The lower half of the bony nasal septum was consistently deviated toward the cleft side, and the nasal tip was deviated to the noncleft side in 60% of the subjects. The anterior nasal spine was deviated to the noncleft side in 73.3% of the subjects and a mean deviation of the anterior nasal spine of 2.84 +/- 3.90 mm toward the noncleft side was measured. Significant sagittal and transverse asymmetry in deeper midfacial regions was not observed. Unilateral dental-arch collapse was observed in 73.3% of the sample, bilateral collapse in 20%, and no collapse in 6.7%. The soft-tissue support of the alveolar margins of the cleft did not show significant differences between the cleft and noncleft sides. CONCLUSIONS: CT is an excellent method for quantifying surface and deep craniofacial structures. Most asymmetries and deformities in the 10- to 14-year-old patients with repaired complete unilateral CLP we studied were in the dentoalveolar area near the cleft and the nasal chamber and not in the deeper regions of the maxillary complex.

Prevalence of malocclusion and assessment of treatment needs in ß-thalassemia major children.

BACKGROUND: The objective of this study is to evaluate the prevalence of malocclusion and treatment needs in transfusion dependent ß-thalassemia major children. METHODS: One hundred transfusion dependent ß-thalassemia major children visiting the Department of Pediatrics were selected randomly and evaluated for malocclusion with Angle's classification and Dewey's modification. The orthodontic treatment needs were also assessed using Grainger's treatment priority index (TPI). The orthodontic treatment needs were compared to normal children. RESULTS: The assessment of treatment needs revealed a higher prevalence of handicapping and severely handicapping malocclusion in thalassemic children compared to normal children. The thalassemic patients were found to show significantly more Angle's Class II malocclusion (55% vs. 15.7%) when compared to normal children. CONCLUSIONS: The higher prevalence of Angle's Class II malocclusion and definitive malocclusion in thalassemic children indicates the importance of preventive orthodontic procedures and efforts towards providing orthodontic treatment to these children.

Role of fluorine-18 fluoride PET-CT scan in the assessment of unilateral condylar hyperplasia in faciomandibular asymmetry patients: a preliminary study.

OBJECTIVES: This prospective study was aimed to determine and quantify the change in mandibular condylar hyperactivity over a period of time by using a fluorine-18 (18F) fluoride PET-computed tomography (CT) scan. MATERIALS AND METHODS: Sixteen patients (age 19.50 ± 2.58 years) with noticeable faciomandibular asymmetry caused by unilateral condylar hyperplasia (UCH) were included in the test group and underwent an 18F-fluoride PET-CT scan at the beginning of the study (T0); these patients were then followed up for a minimum of 12 months, after which the 18F-fluoride PET-CT scan was repeated at first follow-up (T1). An age-matched control group consisted of 10 patients with apparently symmetrical faces whose PET-CT scans were acquired for some other medical conditions. Statistical analysis of maximum standardized uptake values (SUV max) obtained through 18F-fluoride PET-CT was performed using the paired t-test. RESULTS: Mean SUV max of the affected condyle at T0 and T1 was 9.18 ± 4.07 and 9.18 ± 3.88, respectively. The mean SUV max of the contralateral condyle at T0 and T1 was 6.21 ± 2.30 and 6.66 ± 2.64, respectively. The mean right-left difference in tracer uptake between the test and control groups both at T0 and T1 was statistically significant. Right-left percentage difference of isotope uptake of the test group was 16.87 ± 15.75% at T0 and 14.97 ± 12.72% at T1. Right-left percentage difference of isotope uptake of the control group was 5.51 ± 5.72%. Although these differences were statistically significant, their clinical relevance was insignificant. SUV max of the higher uptake side and the lower uptake side of the control group was 5.63 ± 1.85 and 5.09 ± 1.83, respectively. CONCLUSION: Great diversity exists in the clinical presentation of UCH. The growth trend of UCH is highly variable because of the age and sex of patients. The results of the present study show that the 18F-fluoride PET-CT scan may guide us in determining the right time and in making the right choice of surgico-orthodontic intervention in UCH patients. The clinical presentation and SUV max of PET-CT of UCH patients were in agreement with each other. The baseline values of the control group indicated that these could also be used to differentiate normal from abnormal condylar growth in potential class III skeletal pattern cases - that is, patients having sagittal skeletal dysplasia resulting from either maxillary deficiency or mandibular protrusion, or both in combination, thus resulting in a concave facial profile.

Long-Term Effect of Maxillary Distraction Osteogenesis (DO) on Nasal Index in Adult Patients with Cleft Lip and Palate Deformities.

PURPOSE: To test the hypothesis that there is no immediate and long-term effects of maxillary distraction osteogenesis (DO) on nasal index among adult subjects with cleft lip and palate deformities. MATERIALS AND METHODS: Twelve adult subjects in the age range of 17-20 years with complete unilateral cleft lip and palate underwent advancement of maxilla by DO. The immediate and long-term effects of maxillary DO on nasal index were evaluated from extra-oral full face frontal photographs recorded prior to DO (T0), at the end of active DO (T1) and at least 2-years after the DO (T2). The ANOVA, Post Hoc test (Bonferroni) and Pearson correlation coefficients were used. The probability value (P value) 0.05 was considered as statistically significant. RESULTS: SNM angle and Ptm-M distance increased significantly by DO (P < 0.001). The nasal index increased significantly (P < 0.01) by 13.85 % from T0 value of 85.15 ± 4.49 to 99.02 ± 11.16 % at the end of active distraction (T1) and by 12.69 to 97.84 ± 9.14 % at the end of long-term follow-up (T2). The correlation between sagittal maxillary advancement and nasal index was statistically significant (P < 0.001). For each millimeter of maxillary advancement, the nasal index increased by 1.38 % and 1.8 % at the end of active distraction and long-term follow-up respectively. CONCLUSION: The advancement of maxilla by distraction osteogenesis among subjects with cleft lip and palate deformities increased nasal index significantly.

Effects of various remineralizing agents on the outcome of post-orthodontic white spot lesions (WSLs): a clinical trial.

BACKGROUND: One of the most undesirable side effects of comprehensive orthodontic treatment is white spot lesions (WSLs). Despite many attempts at prevention of WSLs, its prevalence remains very high on debonding. There are many agents like fluoride toothpastes, fluoride varnishes, and fluoride mouth rinses, and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) is frequently used for the remineralization of WSLs. However, there is no consensus in the literature with respect to the success rates of these agents. Thus, the present study was designed to evaluate the efficacy of fluoride toothpaste alone and in combination with fluoride varnish and CPP-ACP plus crème in the remineralization of post-orthodontic WSLs. METHODS: Forty-five subjects in the age range of 16-25 years having at least one post-orthodontic WSL were included in the study. All the subjects were randomly divided into three groups (toothpaste group, varnish group, and CPP-ACP group). The efficacy of various remineralizing agents on the remineralization of WSLs was evaluated clinically and by DIAGNOdent immediately after debonding and subsequently after 1, 3, and 6 months of their use. RESULTS: Twice daily use of fluoride toothpaste alone had no significant effect on remineralization of WSLs at various intervals of observations (P = 0.078). Application of fluoride varnish along with twice daily use of fluoride toothpaste for 6 months significantly decreased the severity of WSLs (P < 0.01). Twice daily use of CPP-ACP plus crème along with fluoride toothpaste had significant effect on remineralization of WSLs at the end of 6 months of observation (P < 0.05). Between the group comparison showed that the mean visual and DIAGNOdent scores at various time intervals of observations were decreased more when fluoride varnish and CPP-ACP crème were used in addition to daily use of fluoride toothpaste, but the differences were not statistically significant (P > 0.05). CONCLUSIONS: The use of fluoride varnish and CPP-ACP plus crème in addition to twice daily use of fluoride toothpaste had no additional benefit in the remineralization of post-orthodontic WSLs.

Winged maxillary central incisors with unusual morphology: a unique presentation and early treatment.

Winged incisors are a well-recognized clinical finding. In this report, the disorder is briefly reviewed and a unique case of winging of the two maxillary central incisors having unusual morphology in an eight-year six-month-old boy is presented. The two winged maxillary central incisors were derotated using an anterior sectional wire inserted into a pair of twin brackets, one bonded to each of the two central incisors, and reciprocal anchorage.

Implementation of post treatment critical evaluation improved the quality of orthodontic care in postgraduate orthodontic clinic: A 10 years comparative study.

OBJECTIVE: The aim of the study was to evaluate the effect of post- treatment critical evaluation on the quality of orthodontic care in a postgraduate orthodontic clinic. MATERIALS AND METHODS: Orthodontic treatment outcome of 109 consecutively treated cases was evaluated in Phase-I evaluation. Following Phase-I evaluation, PTCE of each case was made mandatory. After 6-years of implementation of compulsory PTCE for each case, orthodontic treatment outcome of all consecutively treated cases (n = 126) was evaluated (Phase-II). The treatment outcome was evaluated by American Board of Orthodontics Model Grading System (ABO MGS) and Subjective evaluation (Visual Analogue Scale, VAS). RESULTS: Based on the ABO scores, the cases were divided into three grades, that is, Grade-I, Grade-II, and Grade-III. The mean total ABO score was improved significantly in Phase-II evaluation (P < 0.01). The total number of cases in ABO Grade-II were increased significantly (P < 0.01) whereas cases in ABO Grade-I remained comparable. The VAS score was improved from 5.66 ± 0.77 at Phase-I to 6.02 ± 0.99 at Phase-II evaluation (P < 0.01). CONCLUSION: The implementation of PTCE significantly improved the quality of orthodontic care in a postgraduate orthodontic clinic. CLINICAL SIGNIFICANCE: Grading one's own treatment improves the quality of future treatment.

Satisfaction audit of patients undergoing mandibular distraction osteogenesis with extra-oral distraction appliances.

INTRODUCTION: The aim of this research was to evaluate the level of satisfaction of patients who were undergoing distraction osteogenesis of mandible with extraoral distraction appliance. MATERIAL AND METHODS: The prospective study was performed on 13 patients with facio-mandibular deformity reporting to the Oral Health Sciences Center, PGIMER, Chandigarh, India, who required surgical and orthodontic intervention for correction. A standardized multiple choice questionnaire was provided to all patients at 3 stages of treatment i.e. during predistraction, distraction and post distraction period. RESULTS: Predistraction evaluation showed that the main reason for patients to seek treatment was lack of facial esthetics and all of them were sure that there would be a change in their lives after they underwent this treatment procedure. During distraction phase the most common complaint was pain. None of the patients felt that they were suffering during active distraction phase and all felt that they made the right decision. In post distraction phase, all patients were satisfied with the treatment and felt that the treatment was worth it. Twelve out of 13 patients would recommend treatment to others without any hesitation. CONCLUSION: Our study concludes that distraction osteogenesis of the mandible with extra-oral appliances is acceptable to patients, and improved facial appearance is a positive influence. The appliance and results of the procedure are socially accepted and appreciated.

Comparison of risk indicators of dental caries in children with and without cleft lip and palate deformities.

OBJECTIVE: To test the hypothesis that there are no differences in various risk factors of dental caries among children with cleft lip and palate when compared to non-cleft high caries risk and non-cleft caries free children. DESIGN: Seventy-three children in the age range of 4-9 years comprised three groups; Group-I (n = 23, children with cleft lip and palate), Group-II (n = 25, non-cleft high caries risk children) and Group-III (n = 25, non-cleft caries free children). Various risk factors for dental caries like type of oral hygiene practice, sugar exposures/day, developmental defects of enamel, caries activity, salivary streptococci mutans levels and lactobacilli levels were evaluated and compared among the three groups of children. RESULTS: The mean deft score among Group-II children was significantly more (P < 0.01) as compared to the Group-I children. The mean deft + DMFT score among Group-I and Group-II children was comparable (P = 0.149). Developmental enamel defects were more among Group-I children as compared to Group-II and Group-III children (P < 0.01). Hypoplasia of the maxillary anterior teeth was more common among Group-I children as compared to Group-II (P < 0.05) and Group-III children (P < 0.001). The association between hypoplastic teeth and dental caries was significant (P < 0.05). The salivary acidogenic potential as evaluated by Snyder test was comparable among Group-I and Group-II children. The salivary streptococcus mutans levels in Group-I and Group-II children were higher when compared to lactobacillus counts. CONCLUSION: The risk factors of dental caries among children with cleft lip and palate were more as compared to non-cleft high caries risk and non-cleft caries free children.

A normative study to evaluate inclination and angulation of teeth in North Indian population and comparision of expression of torque in preadjusted appliances.

AIM: The aim of this study was to evaluate angulation and inclination of teeth from the study models of individuals with normal occlusion and evaluation of actual expression of torque expressed by three different bracket systems. MATERIALS AND METHODS: In this study, the inclination and angulation were measured on 30 study models of North Indian individuals. A self-developed instrument (torque angle gauge) was used for the measurement. Fifteen study models were duplicated for the evaluation of torque expression in the bracket of three different manufacturers with different shape and size of bases. RESULTS: The results give the mean, minimum and maximum, standard deviation of the normative data individually for each tooth. A significant correlation was noted in the angulation of maxillary canine and first premolar, and between premolars; and between mandibular central incisor with lateral incisor and canine, and between premolars. CONCLUSIONS: There was a highly significant correlation of teeth angulation and inclination in the maxillary and mandibular arch. Though the error in expression of torque was not significant, but it showed a large range, indicating the need to vary the position of brackets in different bracket systems for achieving optimum torque.

Effects of twin-block appliance on the anatomy of pharyngeal airway passage (PAP) in class II malocclusion subjects.

BACKGROUND: The use of functional appliances for the correction of retrognathic mandible is very common in orthodontics. Similar appliances known as oral appliances are also frequently used in adults for the treatment of mild to moderate obstructive sleep apnea (OSA). Many studies have reported improvement of pharyngeal airway passage (PAP) dimensions following functional appliance therapy in children and oral appliance therapy in adults. There is only one study in the literature that discussed the effect of oral appliance therapy on posterior pharyngeal wall thickness (PPWT) among subjects with OSA. The effect of functional appliance therapy on PPWT has never been investigated. Thus the present study was conducted to evaluate the effects of twin-block appliance on pharyngeal airway passage (PAP) dimensions and posterior pharyngeal wall thickness (PPWT) in class II malocclusion subjects with retrognathic mandibles. METHODS: Thirty-eight class II malocclusion subjects in the age range of 8 to 14 years with mandibular retrusion were divided into a treatment (n = 20) and control (n = 18) group. Mandibular retrusion in the treatment group subjects was corrected by twin-block appliance. The effect of twin-block appliance on PAP and PPWT dimensions were evaluated from lateral cephalograms recorded prior-to and after 6 months of appliance therapy in the treatment group subjects and the changes were compared with the changes in the control group subjects. Student's t-test was used for statistical analysis; P-value of 0.05 was considered a statistically significant level. RESULTS: The depth of the oropharynx was increased significantly in the treatment group subjects (P < 0.001) as compared to the control group subjects (P < 0.05). The depth of the hypopharynx increased significantly in treatment group subjects (P < 0.01). The PPWT at the level of the nasopharynx, oropharynx, and hypopharynx were maintained in the treatment group subjects; whereas in control group subjects, the PPWT was further reduced although the changes were not statistically significant. CONCLUSIONS: Correction of mandibular retrusion by twin-block appliance in class II malocclusion subjects increased the PAP dimensions and maintained the pre-treatment thickness of posterior pharyngeal wall.