A Morphological Classification Scheme for the Mandibular Hypoplasia in Treacher Collins Syndrome.

BACKGROUND: Mandibular hypoplasia is a hallmark of Treacher Collins syndrome (TCS), and its severity accounts for significant functional morbidity. The purpose of this study is to develop a mandibular classification scheme. METHODS: A classification scheme was designed based on three-dimensional computed tomography (3D-CT) scans to assess 3 characteristic features: degree of condylar hypoplasia, mandibular plane angle (condylion-gonion-menton), and degree of retrognathia (sella-nasion-B point angle). Each category was graded from I to IV and a composite mandible classification was determined by the median value among the 3 component grades. RESULTS: Twenty patients with TCS, aged 1 month to 20 years, with at least one 3D-CT prior to mandibular surgery were studied. Overall, 33 3D-CTs were evaluated and ordered from least to most severe phenotype with 10 (30%) Grade 1 (least severe), 14 (42%) Grade 2, 7 (21%) Grade 3, and 2 (7%) Grade 4 (most severe). Seven patients had at least 2 longitudinal scans encompassing an average 5.7 (range 5-11) years of growth. Despite increasing age, mandibular classification (both components and composite) remained stable in those patients over time (P = 0.2182). CONCLUSION: The authors present a classification scheme for the TCS mandible based on degree of condylar hypoplasia, mandibular plane angle (Co-Go-Me angle), and retrognathia (SNB angle). While there is a natural progression of the mandibular morphology with age, patients followed longitudinally demonstrate consistency in their classification. Further work is needed to determine the classification scheme's validity, generalizability, and overall utility.

Class II malocclusion division 1: a new classification method by cephalometric analysis.

AIM: The purpose of this study was to analyse the craniofacial and dentofacial skeletal characteristics in untreated subjects with Class II, division 1 malocclusion by mandibular retrusion and to identify different types and their prevalence. MATERIALS AND METHODS: In 152 subjects with Class II, division 1 malocclusion by mandibular retrusion, the differences were determined by lateral cephalograms analysis of variance and chi-square test, respectively. P<0.05 was considered significant. Seven types of mandibular retrusion were identified: three pure, dimensional, rotational and positional, and four mixed. RESULTS: All patients showed significant inter-group differences with P between 0.005 and 0.001. The dimensional type was the most common (28.9%) and the rotational-positional type was the rarest (5.9%). The pure dimensional type had the shortest mandibular body; the pure rotational type had larger SN/GoMe and the lowest AOBO; the pure positional type presented the flattest cranial base, high AOBO. In the mixed types, dento-skeletal features changed depending on how the main types assorted. CONCLUSIONS: Identifying the type of mandibular retrusion is important for differential diagnosis in clinical practice and research.

[Mandibular advancement device: a 5-year long experience in obstructive sleep apnea/hypopnea syndrome]. / Orthèse d'avancée mandibulaire: cinq ans de traitement du syndrome d'apnées-hypopnées obstructives du sommeil.

INTRODUCTION: We assessed the effectiveness of mandibular advancement device (MAD) on 113 patients having consulted in our specialized unit for obstructive sleep apnea syndrome (OSAS), from January 2005 to January 2010. METHODS: We included all adult patients referred by pulmonologists for OSAS. The data collected were gender, age, BMI, dental occlusion, presentation of retromandibulism, apnea hypopnea index (AHI) at diagnosis, and MAD effectiveness (AHI, compliance, satisfaction, tolerance). RESULTS: One hundred and thirteen patients were included, 83 men and 30 women, with an average age of 53.6 years, and average BMI of 26.9. Fifty-eight patients (55.8%) used the MAD regularly, 17 (16.4%) irregularly, and 29 (27.9%) stopped using it. Fifty-seven patients (54.8%) were very satisfied, 20 (19.2%) somewhat satisfied, and 27 (26%) not at all. The average AHI with MAD was 13.3 (±10.3) and the average improvement of AHI was 19 (±14.1). Twenty-seven patients (28.7%) were cured, 46 (48.9%) presented with an AHI decrease greater than 50%, and for 21 (22.3%) the treatment failed. DISCUSSION: The sample of patients in this study has the same characteristics as the general apneic population. Adherence and satisfaction were satisfactory. AHI results were also good but seemed low compared to other studies. This was due to more stringent criteria for cure, more in line with the overall management. No criterion for inclusion was predictive of good tolerance and no score predictive of success could be established. However, the improvement in AHI was significantly correlated to the patient's BMI and its diagnostic AHI.

Long-term follow-up of craniofacial alterations in juvenile idiopathic arthritis.

OBJECTIVE: To investigate changes in the craniofacial skeleton in relation to the changes in condylar alterations that occur during long-term follow-up in patients with juvenile idiopathic arthritis. MATERIALS AND METHODS: Temporomandibular joint (TMJ) involvement is defined as a condylar alteration that is observed on the orthopantomogram. Lateral cephalograms were used to determine linear and angular measurements. RESULTS: Seventy of 97 patients from the initial study cohort were included, with a mean follow-up of 68 months. The overall prevalence of condylar alterations and posterior rotation of the mandible decreased; however, the prevalence of retrognathia remained the same. Patients showed improvement in the degree of retrognathia and posterior rotation (40% ANB, 51% OP-SN, and 44% GO-GN-SN). Improvement in the degree of retrognathia was seen more often in patients with improved condylar alterations than in patients with persistent alterations and in those without alterations (50%, 33%, and 28%, respectively). The degree of posterior rotation improved almost equally in patients without TMJ involvement and in patients with improved condylar alterations (57% and 50% by OP-SN, and 67% and 38% GO-GN-SN, respectively) and did not improve in patients with stable persistent alterations. CONCLUSION: Both condylar and craniofacial alterations can improve in patients with juvenile idiopathic arthritis.

[Classification and operation in the treatment of maxillary retrusion of adult patients with cleft lip and palate].

OBJECTIVE: To classify the patients with cleft lip and palate who need orthognathic surgery and to propose the corresponding operations. METHODS: From January 2005 to May 2015, 121 patients with cleft lip and palate diagnosed as maxillary retrusion were treated by orthognathic surgery. Inclusion criteriar: (1) male aged over 16, female aged over 14; (2) diagnosed as non-syndromic cleft lip and palate without systemic disease and other genetic diseases; (3) without previous orthodontic and orthognathic treatment; (4) having no other craniofacial malformation. Maxillary features and repaired types were recorded. RESULTS: 93 patients were included and divided into two categories depended on the dental crowding. Class I: the teeth quantity and bone quantity is coordinated, space analysis ≤ 4 mm (mild dental crowding). The forward distance of maxillary less than 6 mm was defined as Class I a (36 cases) more than 6 mm as Class I b (28 cases). Class II: the teeth quantity and bone quantity is not coordinated, space analysis > 4 mm ( moderate or severe dental crowding). After the simulation of distraction osteogenesis, the anterior crossbite was corrected defined as Class II a (23 cases), not corrected defined as Class II b (6 cases). Class I a were corrected by conventional orthognathic surgery. While Class I b were corrected by Le Fort I maxillary advancement using distraction osteogenesis. Class II a were repaired just by anterior maxillary distraction. While Class II b need to combine conventional orthognathic surgery with anterior maxillary distraction. All the patients were satisfied with the treatment effect. CONCLUSIONS: The patients of cleft lip and palate with maxillary retrusion who need orthognathic surgery can be classified as the method mentioned above, and then choose the appropriate operations.

Craniofacial skeletal pattern: is it really correlated with the degree of adenoid obstruction?

OBJECTIVE: The aim of this study was to compare the cephalometric pattern of children with and without adenoid obstruction. METHODS: The sample comprised 100 children aged between four and 14 years old, both males and females, subjected to cephalometric examination for sagittal and vertical skeletal analysis. The sample also underwent nasofiberendoscopic examination intended to objectively assess the degree of adenoid obstruction. RESULTS: The individuals presented tendencies towards vertical craniofacial growth, convex profile and mandibular retrusion. However, there were no differences between obstructive and non-obstructive patients concerning all cephalometric variables. Correlations between skeletal parameters and the percentage of adenoid obstruction were either low or not significant. CONCLUSIONS: Results suggest that specific craniofacial patterns, such as Class II and hyperdivergency, might not be associated with adenoid hypertrophy.

Association of systematic head and neck physical examination with severity of obstructive sleep apnea-hypopnea syndrome.

OBJECTIVES/HYPOTHESIS: To identify upper airway and craniofacial abnormalities is the principal goal of clinical examination in patients with obstructive sleep apnea-hypopnea syndrome. The aim was to identify anatomical abnormalities that could be seen during a simple physical examination and determine their correlation with apnea-hypopnea index (AHI). STUDY DESIGN: Consecutive patients with obstructive sleep apnea-hypopnea syndrome who were evaluated in a public otorhinolaryngology center were studied. METHODS: Adult patients evaluated previously with polysomnography met the inclusion criteria. All subjects underwent clinical history and otolaryngological examination and filled out a sleepiness scale. Physical examination included evaluation of pharyngeal soft tissue, facial skeletal development, and anterior rhinoscopy. RESULTS: Two hundred twenty-three patients (142 men and 81 women) were included (mean age, 48 +/- 12 y; body mass index, 29 +/- 5 kg/m2; AHI, 23.8 +/- 24.8 events per hour). Patients were distributed into two groups according to the AHI: snorers (18.4%) and patients with sleep apnea (81.7%). Sleepiness and nasal obstruction were reported by approximately half of patients, but the most common complaint was snoring. There was a statistically significant correlation between AHI and body mass index (P <.000), modified Mallampati classification (P =.002), and ogivale-palate (P <.001). The retrognathia was not correlated to AHI, but the presence of this anatomical alteration was much more frequent in patients with severe apnea when compared with the snorers (P =.05). Other correlations with AHI were performed considering multiple factors divided into two groups of anatomical abnormalities: pharyngeal (three or more) and craniofacial (two or more) abnormalities. There was a statistically significant correlation between pharyngeal landmarks and AHI (correlation coefficient [r] = 0.147, P =.027), but not between craniofacial landmarks and AHI. The combination of pharyngeal anatomical abnormalities, modified Mallampati classification, and body mass index were also predictive of apnea severity. CONCLUSIONS: Systematic physical examination that was used in the present study indicated that, in combination, body mass index, modified Mallampati classification, and pharyngeal anatomical abnormalities are related to both presence and severity of obstructive sleep apnea-hypopnea syndrome. Hypertrophied tonsils were observed in only a small portion of the patients. The frequency of symptoms of nasal obstruction was high in sleep apnea patients. Further studies are needed to find the best combination of anatomical and other clinical landmarks that are related to obstructive sleep apnea.

Association between mandibular retrognathia and TMJ disorders in adult females.

OBJECTIVE: This study assesses the association between temporomandibular joint (TMJ) disorders and mandibular retrognathia. METHODS: We conducted a case-control study among women, aged 18-70 years, recruited from Kaiser Permanente Northwest Division (KPNW, Portland, OR) and Group Health Cooperative of Puget Sound (GHC, Seattle, WA). Cases (N= 160) were women seeking treatment for TMJ disorders at KPNW and GHC clinics. Controls (N=151) were women without TMJ disorders, selected from among adult female dental hygiene patients at KPNW or GHC enrollees. Case status was determined by questionnaire; mandibular sagittal position (orthognathic, mildly retrognathic, severely retrognathic, or prognathic) was measured using digitized facial photographs. Odds ratios (OR) and associated 95 percent confidence intervals (CI) estimated the magnitude of the association between TMJ disorders and mandibular sagittal position. RESULTS: Women with TMJ disorders were 4.0 times (95% CI=1.5, 10.8) more likely than controls to have severe retrognathia; no association with mild retrognathia or prognathia was seen. Results were similar when cases were restricted to those with recent onset of TMJ pain (OR=6.3; 95% CI=1.8, 21.8). CONCLUSIONS: We found a strong association between TMJ disorders and severe mandibular retrognathia in adult females. In some women this likely resulted from TMJ disorders influencing mandibular development over time. However, among a subset of women, our data support the reverse hypothesis--that severe mandibular retrognathia may influence the development of TMJ disorders. Despite this strong association, abnormal mandibular position contributed only a small portion to the overall rate at which women sought treatment for TMJ disorders.

Lateral cephalometric diagnosis of asymmetry in Angle Class II subdivision compared to Class I and II.

INTRODUCTION: Lateral cephalometric radiographs are traditionally required for orthodontic treatment, yet rarely used to assess asymmetries. OBJECTIVE: The objective of the present study was to use lateral cephalometric radiographs to identify existing skeletal and dentoalveolar morphological alterations in Class II subdivision and to compare them with the existing morphology in Class I and II relationship. MATERIAL AND METHODS: Ninety initial lateral cephalometric radiographs of male and female Brazilian children aged between 12 to 15 years old were randomly and proportionally divided into three groups: Group 1 (Class I), Group 2 (Class II) and Group 3 (Class II subdivision). Analysis of lateral cephalometric radiographs included angular measurements, horizontal linear measurements and two indexes of asymmetry that were prepared for this study. RESULTS: In accordance with an Index of Dental Asymmetry (IDA), greater mandibular dental asymmetry was identified in Group 3. An Index of Mandibular Asymmetry (IMA) revealed less skeletal and dental mandibular asymmetry in Group 2, greater skeletal mandibular asymmetry in Group 1, and greater mandibular dental asymmetry in Group 3. CONCLUSION: Both IDA and IMA revealed greater mandibular dental asymmetry for Group 3 in comparison to Groups 1 and 2. These results are in accordance with those found by other diagnostic methods, showing that lateral cephalometric radiography is an acceptable method to identify existing skeletal and dentoalveolar morphological alterations in malocclusions.

Magnetic resonance imaging-verified temporomandibular joint disk displacement in relation to sagittal and vertical jaw deformities.

This retrospective study was designed to analyze the relationships between temporomandibular joint (TMJ) disk displacement and skeletal deformities in orthodontic patients. Subjects consisted of 460 adult patients. Before treatment, lateral cephalograms and TMJ magnetic resonance imaging (MRI) were recorded. Subjects were divided into six groups based on TMJ MRI according to increasing severity of TMJ disk displacement, in the following order: bilateral normal TMJs, unilateral disk displacement with reduction (DDR) and contralateral normal, bilateral DDR, unilateral disk displacement without reduction (DDNR) and contralateral normal, unilateral DDR and contralateral DDNR, and bilateral DDNR. Subjects were subdivided sagittally into skeletal Class I, II, and III deformities based on the ANB (point A, nasion, point B) angle and subdivided vertically into hypodivergent, normodivergent, and hyperdivergent deformities based on the facial height ratio. Linear trends between severity of TMJ disk displacement and sagittal or vertical deformities were analyzed by Cochran-Mantel-Haenszel test. The severity of TMJ disk displacement increased as the sagittal skeletal classification changed from skeletal Class III to skeletal Class II and the vertical skeletal classification changed from hypodivergent to hyperdivergent. There were no significant differences in the linear trend of TMJ disk displacement severity between the sexes according to the skeletal deformities. This study suggests that subjects with skeletal Class II and/or hyperdivergent deformities have a high possibility of severe TMJ disk displacement, regardless of sex.

Lateral cephalometric diagnosis of asymmetry in Angle Class II subdivision compared to Class I and II

INTRODUCTION: Lateral cephalometric radiographs are traditionally required for orthodontic treatment, yet rarely used to assess asymmetries. OBJECTIVE: The objective of the present study was to use lateral cephalometric radiographs to identify existing skeletal and dentoalveolar morphological alterations in Class II subdivision and to compare them with the existing morphology in Class I and II relationship. MATERIAL AND METHODS: Ninety initial lateral cephalometric radiographs of male and female Brazilian children aged between 12 to 15 years old were randomly and proportionally divided into three groups: Group 1 (Class I), Group 2 (Class II) and Group 3 (Class II subdivision). Analysis of lateral cephalometric radiographs included angular measurements, horizontal linear measurements and two indexes of asymmetry that were prepared for this study. RESULTS: In accordance with an Index of Dental Asymmetry (IDA), greater mandibular dental asymmetry was identified in Group 3. An Index of Mandibular Asymmetry (IMA) revealed less skeletal and dental mandibular asymmetry in Group 2, greater skeletal mandibular asymmetry in Group 1, and greater mandibular dental asymmetry in Group 3. CONCLUSION: Both IDA and IMA revealed greater mandibular dental asymmetry for Group 3 in comparison to Groups 1 and 2. These results are in accordance with those found by other diagnostic methods, showing that lateral cephalometric radiography is an acceptable method to identify existing skeletal and dentoalveolar morphological alterations in malocclusions. .

INTRODUÇÃO: as telerradiografias laterais são tradicionalmente solicitadas para planejamento ortodôntico, mas raramente utilizadas para avaliar assimetrias. OBJETIVO: o objetivo do presente estudo foi utilizar as telerradiografias laterais para identificar as alterações morfológicas esqueléticas e dentoalveolares existentes na má oclusão de Classe II subdivisão e compará-las com a morfologia existente nas más oclusões de Classe I e II. MÉTODOS: noventa telerradiografias laterais iniciais de adolescentes brasileiros de ambos os sexos, com idade cronológica entre 12 e 15 anos, foram divididas em três grupos randomizados e proporcionais: Grupo 1 (Classe I), Grupo 2 (Classe II) e Grupo 3 (Classe II subdivisão). A análise das telerradiografias laterais envolveu mensurações angulares, mensurações lineares horizontais e dois índices de assimetria, estipulados para o presente estudo. RESULTADOS: foi identificada, de acordo com o Índice de assimetria dentária (IAD), uma maior assimetria dentária inferior no Grupo 3. O Índice de assimetria mandibular (IAM) revelou menor assimetria esquelética e dentária no Grupo 2, maior assimetria esquelética no Grupo 1 e maior assimetria dentária inferior no Grupo 3. CONCLUSÃO: o IAD e o IAM mostraram maior assimetria dentária inferior no Grupo 3 do que nos Grupos 1 e 2. Esses resultados estão de acordo com os encontrados em outros métodos de diagnóstico, indicando que a telerradiografia lateral é um método aceitável para avaliar alterações morfológicas esqueléticas e dentoalveolares nas más oclusões. .

Comparison of soft and hard tissue profiles of orthognathic surgery patients treated recently and 20 years earlier.

The aim of this study was to assess, by means of lateral cephalometric radiographs, any differences in the pretreatment soft and hard tissue facial profiles of patients who relatively recently underwent orthognathic surgery compared with those whose surgery occurred 20 years before. The pretreatment soft and hard tissue profiles of 91 orthognathic surgery patients were analyzed. These patients were divided into 2 groups. The first group consisted of 35 patients that were treated within the period from 1982 to 1986. The second group included 56 patients treated between 2000 and 2002. To assess patients' hard and soft tissue profiles, 4 cephalometric variables were evaluated on their pretreatment lateral cephalograms. For each of the 4 variables used, the patients were divided into one of 3 different profile subgroups: orthognathic, retrognathic, or prognathic profile. According to the distribution of profiles in each of the 2 groups, a qualitative comparison was made. Descriptive statistics and chi-squared tests were performed to access the possible differences at P < .05. By comparing pretreatment facial profiles between the 2 groups using the soft and hard tissue measurements, it was demonstrated that some changes actually occurred over the years. These differences in the profiles between the 2 groups indicated that orthodontic-surgical patients treated more recently exhibited smaller deviations from the norm than those treated in the earlier period. These findings may reflect possible changes in what is currently considered to be acceptable.

Treatment outcomes of growing Class II Division 1 patients with varying degrees of anteroposterior and vertical dysplasias, Part 2. Profile silhouette evaluation.

The purpose of this study was to evaluate pretreatment and posttreatment soft tissue profiles of 4 groups of growing Class II Division 1 patients treated with fixed orthodontic appliances and headgear. One hundred patients were grouped according to the severity of their initial retrognathia and vertical skeletal status. Standardized pretreatment and posttreatment profile silhouettes of each patient were randomized and projected for scoring by panels of lay persons and orthodontic residents. Statistical analysis consisting of nonparametric procedures showed that (1) as the initial skeletal discrepancies between the 4 groups worsened, the initial profiles were judged to be more unattractive (P <.001); (2) there was no perceived difference in the final profiles between the 4 groups; and (3) significantly greater improvement was measured for those with greater initial skeletal discrepancies (P <.05). This study demonstrated that, with appropriate and timely treatment with fixed orthodontic appliances and headgear, growing Class II Division 1 patients can undergo significant profile improvement, and, on average, even those more severely affected can achieve profile improvement so that they can be judged as attractive as those initially less severely affected.

Treatment outcomes of growing Class II Division 1 patients with varying degrees of anteroposterior and vertical dysplasias, Part 1. Cephalometrics.

The purpose of this retrospective study was to evaluate the differences in orthodontic treatment outcomes for 5 groups of growing Class II Division 1 patients with various anteroposterior and vertical skeletal dysplasias. Pretreatment and posttreatment cephalograms of 100 patients were evaluated for soft and hard tissue treatment effects and differences between groups. Changes from pretreatment to posttreatment differed between groups in correction of overjet and change in ANB angle (P <.05). Those with the largest skeletal dysplasias had the greatest skeletal correction but also retained the largest ANB angles posttreatment. Additional correction was achieved through dentoalveolar change with the greatest uprighting of maxillary incisors occurring in patients who initially were the most severely affected (P <.05); this effect was accompanied by an increase in nasolabial angle. All groups had similar changes in mandibular incisor positions, and final positions of the mandibular incisors did not differ between groups. Compared with norms, Z angles and facial contour angles showed discrimination between the most and least severely affected patients based on combined anteroposterior and vertical dysplasias (P <.05). However, there were no clear-cut divisions between the groups, especially with regard to soft tissue cephalometric outcomes. Further evaluation of profile esthetics follows in Part 2. We conclude that conventional orthodontic therapy successfully corrects Class II Division 1 malocclusions in growing patients through a combination of skeletal and dentoalveolar changes, with the greatest changes occurring in patients who initially have the most severe skeletal dysplasias.