Evaluation of mandibular growth in a prepubertal Class I and Class II population: a longitudinal analysis.

OBJECTIVE: This study aims to identify the presence, timing, and magnitude of a prepubertal mandibular growth spurt in a Class I and Class II population. METHODS: From the Burlington and Iowa Growth study of the AAOF Craniofacial Growth Legacy Collection, 83 Class I subjects (37 females and 46 males) and 32 Class II subjects (18 males and 14 females) were identified, as having at least seven consecutive annual lateral cephalograms taken from 5 to 11 years of age. Only subjects with a normodivergent facial pattern were considered. A customized cephalometric analysis was performed, and total mandibular length, defined as the distance between Condylion (Co) and Gnathion (Gn), was calculated. RESULTS: Overall, a significant early peak of mandibular growth was present in all the subjects analysed both in Class I (4.69 mm for males and 4.18 mm for females; P < .05) and in Class II (5.85 mm for males and 4.05 mm for females; P < .05). No differences between males and females were found for the timing of this peak (7 years for Class I and Class II females and 7 years for Class I and 6.5 years for Class II males). In males, a significantly larger peak was observed in Class II than Class I subjects (P = .007). LIMITATIONS: The main limitations of this study were the impossibility of using a suitable growth indicator to identify the timing of the early mandibular growth peak and the limited Class II records retrievable. CONCLUSION: This investigation suggests that a prepubertal mandibular growth peak is consistently present in both Class I and Class II males and females of clinically significant magnitude. Despite that, chronological age confirms to be unsuitable to identify this peak.

Duration of stages of the Middle Phalanx Maturation method in a contemporary population: A 6-year longitudinal analysis.

OBJECTIVE: To determine the duration and age at the beginning of each stage corresponding to the circumpubertal period in the Middle Phalanx Maturation method (MPM) and to assess the differences between males and females. MATERIALS AND METHODS: Sets of X-rays of the middle phalanx of the third finger taken at 6-month intervals were analysed for 246 skeletal Class I subjects (102 females and 144 males) between 9 and 15 years of age. After staging, the duration of each stage was derived from chronological ages, and the difference between males and females for both duration and age at the beginning of each stage was investigated. RESULTS: The median duration for MPS2 and MPS3 was 1 year for both sexes, while MPS4 showed a median duration of 1 year in females and 9 months in males, with no significant differences between the sexes. Mean age at the beginning of MPS2 was 10y11m for females and 11y11m for males; for MPS3, it was 11y8m for females and 13y1m for males; for MPS4, it was 12y9m for females and 13y11m for males; for MPS5, it was 13y4m for females and 14y3m for males. The differences between the sexes were statistically significant for all the stages (P < .001). CONCLUSIONS: This study confirms, with relevant sample size, the median duration of 1 year for each MPM stage from MPS2 to MPS4. Despite the distinctive interindividual variability, the interquartile range is 6 months or less for all but one interval, confirming the soundness of the results.

Artificial intelligence to support early diagnosis of temporomandibular disorders: A preliminary case study.

BACKGROUND: Temporomandibular disorders (TMDs) are disabling conditions with a negative impact on the quality of life. Their diagnosis is a complex and multi-factorial process that should be conducted by experienced professionals, and most TMDs remain often undetected. Increasing the awareness of un-experienced dentists and supporting the early TMD recognition may help reduce this gap. Artificial intelligence (AI) allowing both to process natural language and to manage large knowledge bases could support the diagnostic process. OBJECTIVE: In this work, we present the experience of an AI-based system for supporting non-expert dentists in early TMD recognition. METHODS: The system was based on commercially available AI services. The prototype development involved a preliminary domain analysis and relevant literature identification, the implementation of the core cognitive computing services, the web interface and preliminary testing. Performance evaluation included a retrospective review of seven available clinical cases, together with the involvement of expert professionals for usability testing. RESULTS: The system comprises one module providing possible diagnoses according to a list of symptoms, and a second one represented by a question and answer tool, based on natural language. We found that, even when using commercial services, the training guided by experts is a key factor and that, despite the generally positive feedback, the application's best target is untrained professionals. CONCLUSION: We provided a preliminary proof of concept of the feasibility of implementing an AI-based system aimed to support non-specialists in the early identification of TMDs, possibly allowing a faster and more frequent referral to second-level medical centres. Our results showed that AI is a useful tool to improve TMD detection by facilitating a primary diagnosis.

Prevalence of oral behaviours in general dental patients attending a university clinic in Italy.

BACKGROUND: Oral behaviors represent a diverse array of habits beyond the physiological behaviors of the stomatognathic system. OBJECTIVE: To describe the prevalence of different oral behaviors, as reported with the Oral Behavior Checklist (OBC-21), in a convenience sample of patients attending an Italian university clinic for routine dental cares. METHODS: In this study, charts of adult patients presenting to the dental department of a regional hospital in Trieste, Italy, from January 2018 and January 2019 were reviewed. Patients with complete files were retrieved, and those with orofacial pain complaints were excluded. OBC-21 scores and grades (score of 0 corresponding to no risk, 1-24 to low risk, and higher than 24 to high risk) were analyzed and stratified according to age and sex. RESULTS: Data from a total of 1424 patients were reported. The overall mean OBC score was 13.3 ± 9.9, with 6.7% no-risk grade, 79.6% low-risk grade, and 13.7% high-risk grade. In general, mean OBC scores decreased with increasing age. Females showed a higher frequency of high-risk grade than males. Most frequent prevalent habits included yawning (73.1%), eating between meals (66.9%) and chewing food on one side only (63.3%). Other behaviors were also highly prevalent, including pressing, touching, or holding teeth together other than while eating (52.7%) and awake clenching (47.5%). CONCLUSION: A low-risk grade of oral behaviors has been found to be frequent in our sample. Future studies are warranted to confirm these findings in larger, representative general populations and to assess if any of these habits are linked to negative effects on the stomatognathic system.

Bone quality in relation to skeletal maturation in palatal miniscrews insertion sites.

INTRODUCTION: This study aimed to investigate the relationship between bone density and quantity at the insertion sites of palatal miniscrews and skeletal maturation-evaluated with the middle phalanx maturation method-in growing patients. METHODS: Sixty patients were analyzed as having a staged third finger middle phalanx radiograph and a cone-beam computed tomography of the maxilla. On the cone-beam computed tomography, a grid was designed to parallel the midpalatal suture (MPS) and posterior to the nasopalatine foramen, both on the palatal and lower nasal cortical bones. Bone density and thickness were measured at the intersections, and medullary bone density was also calculated. RESULTS: Of patients in MPS stages 1-3, 67.6% showed a mean palatal cortical thickness of <1 mm, whereas in 78.3% of the patients in stages 4 and 5, it was >1 mm. The nasal cortical thickness showed a similar trend (MPS stages 1-3: 62.16% <1 mm; MPS stages 4 and 5: 65.2% >1 mm). There was a significant difference in the density of the palatal cortical bone between MPS stages 1-3 (1272.05 ± 191.13) and stages 4 and 5 (1572.33 ± 274.89) and in nasal cortical density between MPS stages 1-3 (1428.09 ± 198.97) and stages 4 and 5 (1597.97 ± 267.75) (P <0.001). CONCLUSIONS: This study revealed a correlation between skeletal maturity and maxillary bone quality. MPS stages 1-3 have lower palatal cortical bone density and thickness but high nasal cortical bone density values. MPS stage 4 and, even more, stage 5 show increasing palatal cortical bone thickness and palatal and nasal cortical bone density values.

Does the planned miniscrew position reflect the achieved one? A clinical study on the reliability of guided miniscrew insertion using lateral cephalogram and maxillary stereolithography file for planning.

INTRODUCTION: The anterior area of the palate is widely used as an insertion site for orthodontic miniscrews. These temporary anchorage devices can be placed either directly or using an insertion guide, and various kinds of digital planning and guides are currently available. This study aimed to verify if the guided procedure can guarantee the correct position of the miniscrews on the patient compared with the digital project. METHODS: Twenty-five consecutively treated patients were included in the study. Angular and linear displacements of the miniscrews were evaluated among 3 groups: the planned position, the model position, and the achieved position. RESULTS: The median achieved angle between 2 digitally planned screws was 6.22° (interquartile range: 4.35°, 9.08°) and the difference between the angles in the planning and the achievement groups was significant (P <0.001). Lateral and vertical differences were also found among the 3 groups. CONCLUSIONS: Results show that the examined workflow is clinically efficient. Differences between the digitally planned position of the orthodontic miniscrews, the control position, and the achieved position were detected both for angular and linear measurements but were not clinically significant.

Skeletal expansion using a miniscrew-assisted rapid palatal expansion in a 50-year-old patient.

This case report illustrates a nonsurgical treatment plan using a miniscrew-assisted rapid palatal expander (MARPE) in a 50-year-old patient with maxillary transverse deficiency. The MARPE appliance consisted of a conventional Hyrax expander anchored to 4 orthodontic miniscrews. The exact locations of the miniscrews were determined with virtual planning software. Cone-beam computed tomography (CBCT) scans were superimposed on the maxillary digital model, and 3-dimensional-printed surgical guides were used to accurately position the mini-implants. A slow expansion protocol was used, and the appliance was held in place during the entire treatment (almost 20 months). Pretreatment, postexpansion, and posttreatment CBCT scans show the parallel expansion obtained without dental torque compensation or bite opening. The posttreatment scan showed that a long period is required to complete the midpalatal suture mineralization. MARPE has proven effective in correcting transverse discrepancies, even in adults. However, posttreatment CBCT imaging showed incomplete ossification of the midpalatal suture, demonstrating that the retention period should be extended in some adult patients.

Circumpubertal maxillomandibular growth in untreated subjects with skeletal Class II relationship: A controlled longitudinal study according to the third finger middle phalanx maturation.

INTRODUCTION: Despite the substantial prevalence of skeletal Class II Division 1 malocclusion, only a few studies analyzed the maxillomandibular growth changes in these subjects with contrasting results. This study compared the longitudinal maxillomandibular growth changes in growing subjects with Class I and II skeletal relationships, specifically during the circumpubertal growth phase assessed by the modified third finger middle phalanx maturation (MPM) method. An attempt to uncover any maxillomandibular growth peak in subjects with Class II relationship has been followed. METHODS: From the files of the Burlington Growth Study, a total of 32 subjects (13 males, 19 females) with at least 7 annual lateral cephalograms taken at 9 and 16 years old were included and equally distributed between Class II and Class I groups matched for sex. Overall changes in 12 cephalometric parameters were calculated, and maxillomandibular growth peak was also identified individually and used to register subjects according to the year of growth peak ± 2 years. According to this procedure, annualized changes (trends) were analyzed along with the corresponding prepubertal, pubertal, and postpubertal MPM stages. RESULTS: No significant differences were seen between subjects with Class I and II skeletal relationships at 9 and 16 years, except for the parameters of the sagittal maxillomandibular relationship, such as ANB angle. Overall, changes for all the cephalometric parameters were similar between the groups, except for the CoGn distance increment that was significantly lower in the subjects with a Class II relationship. In both groups, the annual changes in CoA, CoGn, and CoGo distances showed a clear peak at the time point corresponding to a median MPM stage 3. CONCLUSIONS: In subjects with a skeletal Class II relationship, mandibular deficiency appears to be mostly established during the prepubertal growth stage and further aggravated during puberty. However, the maxillomandibular growth trend in subjects with Class II relationship is generally similar to that of subjects with a Class I relationship, including the existence of a pubertal peak.

Cervical vertebral maturation: Are postpubertal stages attained in all subjects?

INTRODUCTION: The cervical vertebral maturation (CVM) method comprises 6 stages reported to be prepubertal (1 and 2), pubertal (3 and 4) and postpubertal (5 and 6), and its use has been recommended for planning treatment timing in orthodontics. Reliable use of the method implies that pubertal stages have to mature into postpubertal as soon as the growth peak is terminated. The present study was aimed at determining whether postpubertal CVM stages 5 or 6 are attained in all subjects. METHODS: A total of 450 adult subjects (270 females and 180 males; mean age, 30.4 ± 27.3 years; range, 20-45 years) seeking orthodontic treatment and having a lateral head film were included in the study. Customized cephalometric analysis was used, and each recording was converted into an individual CVM code according to the concavities of the C2 to C4 and shapes of C3 and C4. The retrieved CVM codes, either falling within the reported norms (regular cases) or not (exception cases), were also converted into the CVM stages and a newly introduced CVM score (0-9) capable of defining intermediate stage. RESULTS: The most frequent CVM stage was 5, while the CVM stage 6 was attained in only one third of the sample. Up to about 11% of adult subjects showed the pubertal CVM stage 4. Irrespective of the CVM stage or CVM score, no significant differences were seen between the sexes or across ages. The C4 showed a rectangular vertical shape in only 16.4% of the cases. CONCLUSIONS: The percentage of adult population maintaining a pubertal CVM stage 4 is not high, but still relevant from a clinical standpoint. In light of this finding, planning treatment timing-based only on CVM appears not fully reliable.

Cervical vertebral maturation method and mandibular growth peak: a longitudinal study of diagnostic reliability.

Background/objectives: The capability of the cervical vertebral maturation (CVM) method in the identification of the mandibular growth peak on an individual basis remains undetermined. The diagnostic reliability of the six-stage CVM method in the identification of the mandibular growth peak was thus investigated. Subjects/Methods: From the files of the Oregon and Burlington Growth Studies (data obtained between early 1950s and middle 1970s), 50 subjects (26 females, 24 males) with at least seven annual lateral cephalograms taken from 9 to 16 years were identified. Cervical vertebral maturation was assessed according to the CVM code staging system, and mandibular growth was defined as annual increments in Co-Gn distance. A diagnostic reliability analysis was carried out to establish the capability of the circumpubertal CVM stages 2, 3, and 4 in the identification of the imminent mandibular growth peak. Results: Variable durations of each of the CVM stages 2, 3, and 4 were seen. The overall diagnostic accuracy values for the CVM stages 2, 3, and 4 were 0.70, 0.76, and 0.77, respectively. These low values appeared to be due to false positive cases. Limitations: Secular trends in conjunction with the use of a discrete staging system. In most of the Burlington Growth Study sample, the lateral head film at age 15 was missing. Conclusions/Implications: None of the CVM stages 2, 3, and 4 reached a satisfactorily diagnostic reliability in the identification of imminent mandibular growth peak.

Cervical vertebral maturation: An objective and transparent code staging system applied to a 6-year longitudinal investigation.

INTRODUCTION: To date, little information is available regarding individual cervical vertebral maturation (CVM) morphologic changes. Moreover, contrasting results regarding the repeatability of the CVM method call for the use of objective and transparent reporting procedures. In this study, we used a rigorous morphometric objective CVM code staging system, called the "CVM code" that was applied to a 6-year longitudinal circumpubertal analysis of individual CVM morphologic changes to find cases outside the reported norms and analyze individual maturation processes. METHODS: From the files of the Oregon Growth Study, 32 subjects (17 boys, 15 girls) with 6 annual lateral cephalograms taken from 10 to 16 years of age were included, for a total of 221 recordings. A customized cephalometric analysis was used, and each recording was converted into a CVM code according to the concavities of cervical vertebrae (C) C2 through C4 and the shapes of C3 and C4. The retrieved CVM codes, either falling within the reported norms (regular cases) or not (exception cases), were also converted into the CVM stages. RESULTS: Overall, 31 exception cases (14%) were seen. with most of them accounting for pubertal CVM stage 4. The overall durations of the CVM stages 2 to 4 were about 1 year, even though only 4 subjects had regular annual durations of CVM stages 2 to 5. CONCLUSIONS: Whereas the overall CVM changes are consistent with previous reports, intersubject variability must be considered when dealing with individual treatment timing. Future research on CVM may take advantage of the CVM code system.

Diagnostic reliability of the third finger middle phalanx maturation (MPM) method in the identification of the mandibular growth peak.

Background/objectives: The use of the sole third finger middle phalanx for a maturational method has been proposed but not fully investigated. Herein, the diagnostic reliability of an improved five-stage third finger middle phalanx maturation (MPM) method in the identification of mandibular growth peak has been investigated. Subjects/methods: From the files of the Burlington Growth Study, 35 subjects (20 males, 15 females) with at least 7 annual lateral cephalograms taken from 9 to 16 years were included. Mandibular growth was defined as annual increments in condylion-gnathion (Co-Gn) distance. Subsequently, individual annual increments in Co-Gn were arranged according to annual age intervals, with the first and last intervals defined as 9-10 years and 14/15-16 years, respectively. A full diagnostic reliability analysis (including positive likelihood ratio) was performed to establish the diagnostic reliability of the MPM stage 2 (MPS2) in the identification of the imminent mandibular growth peak. Results: The MPS2 had a satisfactory accuracy in the identification of imminent mandibular growth peak with an overall positive likelihood ratio of 10.3. However, reliability showed noteworthy variability being greater and lower for younger and older age intervals, respectively. Limitations: Secular trend, limited sample size, and annual recording in conjunction with the use of a discrete staging system. At the 15 years recording, 28 of 35 cases were missing. Conclusions/implications: The MPS2 and MPS3 may be considered associated with the onset and maximum mandibular growth peak, respectively, in most of the subjects, indicating their use in planning treatment timing.

Facial soft tissue changes during the pre-pubertal and pubertal growth phase: a mixed longitudinal laser-scanning study.

BACKGROUND/OBJECTIVES: Facial soft tissues changes during growth roughly tend to mimic the underlying hard tissues, but not completely. The aim of this mixed longitudinal study was to assess facial growth among pre-pubertal and pubertal subjects without malocclusion using a non-invasive three-dimensional laser scanning system. SUBJECTS/METHODS: Fifty-nine subjects (30 females and 29 males) aged at baseline 5.4-8.9 years with normal occlusion were clustered into the younger, older pre-pubertal, and pubertal groups according to age and the absence/presence of a standing height growth spurt. Three-dimensional facial images were obtained using laser scanners for five consecutive years. Several transversal, sagittal, and vertical parameters were assessed for between and within group comparisons. RESULTS: Significant overall changes of almost all parameters were seen within each group (P < 0.05) without any group differences (P > 0.05). The younger pre-pubertal group showed greater annual growth rates of lip prominence; both pre-pubertal groups showed greater rates in facial middle third height. The pubertal group showed greater annual rates in facial profile angle changes during the growth peak. LIMITATIONS: A high standing height increment (7cm) was used as the threshold for subject allocation in the pubertal group. CONCLUSIONS: Soft tissue facial growth has generally similar amounts and rates irrespective of the pubertal growth spurt. Pre-pubertal subjects show greater annual rates of facial middle third height changes while pubertal subjects show greater annual rates of chin protrusion.

Gingival crevicular fluid alkaline phosphate activity during the retention phase of maxillary expansion in prepubertal subjects: A split-mouth longitudinal study.

INTRODUCTION: The aim of this study was to monitor the alveolar bone formation at the tension sites of teeth supporting the appliances for rapid maxillary expansion (RME) during the retention phase according to the local gingival crevicular fluid (GCF) alkaline phosphatase (ALP) activity. METHODS: This split-mouth prospective study included 23 prepubertal subjects (15 girls, 8 boys; mean age, 9.0 ± 1.4 years) who had a constricted maxillary arch and were undergoing RME. Periodontal parameters, including probing depth, were recorded at 3 and 6 months after RME. Furthermore, the GCF ALP activity was measured at the tension sites of the supporting test teeth (TT) and at the antagonist control teeth (CT) sites. RESULTS: Periodontal parameters were generally similar between the TT and CT sites during the study, with the exception that probing depth underwent a slight increase at the TT sites. At baseline, the GCF ALP activity was similar between the TT and CT sites; however, at both 3 and 6 months, significantly greater enzymatic activity was seen at the TT sites. The overall probing depth changes were not significantly correlated with the corresponding GCF ALP activity changes for either the TT or the CT sites. CONCLUSIONS: Alveolar bone formation at the tension sites would last up to 6 months of retention after RME. These results warrant more comprehensive studies to assess whether the GCF ALP activity has potential as a diagnostic tool for bone formation during the retention phase of RME.

Prevalence of Temporomandibular Disorders (TMD) in Dental Patients at a Specialized Regional Medical Center in Italy.

BACKGROUND AND AIM: This study aimed to evaluate the prevalence of temporomandibular disorders (TMDs) in a sample of general dental patients seeking dental treatments in a northeastern Italian university clinic. MATERIALS AND METHODS: Records of all patients presented for the first time to the dental division of Maggiore Hospital, Italy, between January 1, 2016, and December 31, 2017, were collected. Patients comprised those presenting to the dental clinics for non-TMD complaints, who, upon general examination, were found to have TMD signs and were referred for TMD evaluation. Data were extracted and analyzed, retrospectively. The prevalence of TMDs, age, gender, signs, and symptoms were evaluated. RESULTS: Out of the 18,774 patients studied, 284 had signs of TMD. Women predominance was evident (73%), and patients aged 45-50 were the most frequent sub-population within the TMD population. Clicking was the most commonly present symptom (26.8%), and arthralgia was most commonly diagnosed among this sample (30.7%). A considerable number of patients suffered from muscular disease (myalgia and myofascial pain with 10.1% and 20.7% of the patients, respectively). Significant associations were found among those with myofascial pain on the one hand and degenerative disease and disc displacement with reduction, on the other hand. Furthermore, disc displacement with reduction on one side was associated with displacement without reduction on the other side. CONCLUSION: A considerable number of patients presenting with dental complaints may have asymptomatic TMDs. This highlights the importance of systematic screening of dental patients for TMDs as part of general assessment.

Reliability of a novel CBCT-based 3D classification system for maxillary canine impactions in orthodontics: the KPG index.

The aim of this study was to evaluate both intra- and interoperator reliability of a radiological three-dimensional classification system (KPG index) for the assessment of degree of difficulty for orthodontic treatment of maxillary canine impactions. Cone beam computed tomography (CBCT) scans of fifty impacted canines, obtained using three different scanners (NewTom, Kodak, and Planmeca), were classified using the KPG index by three independent orthodontists. Measurements were repeated one month later. Based on these two sessions, several recommendations on KPG Index scoring were elaborated. After a joint calibration session, these recommendations were explained to nine orthodontists and the two measurement sessions were repeated. There was a moderate intrarater agreement in the precalibration measurement sessions. After the calibration session, both intra- and interrater agreement were almost perfect. Indexes assessed with Kodak Dental Imaging 3D module software showed a better reliability in z-axis values, whereas indexes assessed with Planmeca Romexis software showed a better reliability in x- and y-axis values. No differences were found between the CBCT scanners used. Taken together, these findings indicate that the application of the instructions elaborated during this study improved KPG index reliability, which was nevertheless variously influenced by the use of different software for images evaluation.

Diagnostic performance of 3-dimensional evaluation of palatal vault changes in assessing successful treatment of constricted maxilla in growing subjects.

INTRODUCTION: The success of maxillary expansion should not be assessed solely by the elimination of the teeth in crossbite; it should also be defined as the reestablishment of normal maxillary growth. The aim of this research was to quantify longitudinal palatal changes in children treated for maxillary constriction associated with functional crossbite. METHODS: The subjects included 48 white children (mean age, 5.2 ± 0.6 years), divided into a treatment group (n = 23) and a control group (n = 25). Children in the treatment group had maxillary constriction associated with functional crossbite and were treated with a cemented acrylic splint expander. Dental casts were collected at baseline and at 6, 12, 18, 30, 42, and 54 months later. The casts were scanned with a laser scanner, and the palatal surface areas and volumes, and their increments over time were calculated. Nonparametric tests were used for the data analysis. The diagnostic performance in assessing successful treatment of palatal constriction was evaluated by receiver operating characteristic curves. RESULTS: Significantly greater increments in palatal surface area and volume were seen in the treatment group up to 30 months (P <0.05, at least). According to the receiver operating characteristic curves, the best overall diagnostic performance in terms of accuracy was for palatal volume at 18 months, reaching up to a value of 0.85, by using a cutoff value of increments of 13.5%. CONCLUSIONS: An increase in palatal volume of at least 13.5% at 18 months after treatment is a good indicator to assess the reestablishment of normal growth in subjects treated for maxillary constriction in the deciduous dentition.