Orthodontic findings in adults with Trisomy 21.

OBJECTIVES: Objective of this study was to describe orthodontic findings in adults with Down's syndrome, a matter insufficiently regarded in literature. MATERIALS AND METHODS: A group of 104 adults (33.8 ± 15 years) with trisomy 21 had an orthodontic check-up in their accustomed environment. Anamnestic and dental findings completed the examination and descriptive analysis was performed using SPSS23. Relative frequencies with 95% confidence intervals were compared to the average population (SHIP-study, 2003; DMS IV, 2006). RESULTS: Among the participants 46.2% (36.3-56.2%) (SHIP 36.7%) had already undergone orthodontic treatment. In 87.5% (79.6-93%) of the patients, less than 25.6 properly functioning permanent teeth (DMS IV's mean) were found. Gingival bleeding and recessions, as well as periodontal disease, were increasingly found in older affected persons. Patients with Down's syndrome showed less crowding, e.g., maxillary incisors 28% (19.3-39%) versus 41.9% (SHIP). Frontal open bite (35.2% (25.3-46.1%) versus 3.6% (SHIP)) and frontal crossbite (40.9% (30.5-51.9%) versus 4.2% (SHIP)) were more often observed. No considerable differences in frequencies of orthodontic findings were detected in the comparison of the subgroups "18-28 years" versus ">28 years", "with" versus "without orthodontic treatment", "male" versus "female", "with" versus "without periodontal problems", or "with" versus "without orofacial disturbances". CONCLUSIONS: Within the bounds of this study, we gathered orthodontic findings in adults with trisomy 21 for the first time. In comparison to the average population, the subject group showed a greater number of complex orthodontic findings. CLINICAL RELEVANCE: These persisting dental and orofacial problems must be considered when treating patients with Down's syndrome.

Multibracket appliance: impression defaults and their reduction by blocking-out - a three-dimensional study.

OBJECTIVES: This study examines accuracy of dental impressions and following plaster models taken during treatment with fixed appliances. MATERIALS AND METHODS: A maxillary typodont was provided with brackets. Three examiners took impressions three times each of the variants: brackets only, archwire fixed by alastics, ligatures or Kobayashi-hooks, and brackets and archwire covered completely or just on the gingival side by protection or impression wax. Casts were scanned using Activity102(®). Virtual models were compared to the scan of the typodont using Comparison(®). Differences were measured and descriptively analyzed. Estimated means with 95% confidence intervals were computed. Significance was assessed using linear mixed models. RESULTS: While pyramidal reference blocks had a mean difference of 0.019 mm (95% CI = 0.017-0.021 mm) to the master model, teeth without attachments showed 0.097 mm (95% CI = 0.082-0.111 mm), and teeth with brackets 0.169 mm (95% CI = 0.156-0.182 mm) (p < 0.001). Smallest mean was found when using protection wax only on the gingival bracket side (0.152 mm (95% CI = 0.113-0.192 mm)). Incisors deviated most (0.258 mm (95 % CI = 0.239-0.277 mm)). CONCLUSIONS: Teeth with brackets make impressions more inaccurate because of undercuts. Removing the archwire before taking the impression or covering the brackets on the gingival side shows tendencies toward better precision. CLINICAL RELEVANCE: Taking impressions during treatment with fixed appliances, some inaccuracy has to be taken into account.

Effectiveness of maxillary protraction using facemask with or without maxillary expansion: a systematic review and meta-analysis.

OBJECTIVES: Class III therapy using a face mask is a common approach for treatment of a deficient maxilla and reverse overbite. Usually, maxillary protraction is combined with transverse palatal expansion using intraoral appliances. The purpose of this study was to systematically review the effectiveness of face mask therapy in combination with concepts of palatal expansion and compression. MATERIAL AND METHODS: A systematic review and meta-analysis were performed to identify studies that address class III treatment using a face mask. The search was carried out using common electronic databases as well as hand search. Both screening and study eligibility analysis were performed with consideration of PRISMA and Cochrane Guidelines for systematic reviews. Several terms describing class III face mask treatment were searched. Particular attention was paid to new strategies of enhancing maxillary protraction. RESULTS: The initial search identified 2048 studies. After a thorough selection process, a total of 22 articles met the inclusion criteria. After assessment of the individual quality scoring of each article, eight studies were provided for meta-analysis of the cephalometric parameters. The statistical analysis of treatment changes advocates a positive influence on sagittal maxillary development, which is not primarily influenced by transverse expansion. Dental side effects are more distinct when no expansion was carried out. For the concept of alternating activation/deactivation of the expansion appliance (alt-RAMEC), two articles of high methodological scoring were identified. They indicate an enhancement of face mask treatment. CONCLUSIONS: The findings are consistent with results of previous literature studies regarding the efficiency of class III face mask treatment. A further need for more randomized controlled studies was identified especially with regard to the new concept of alternating maxillary expansion and compression, which showed a positive influence on the maxillary protraction based on two studies. CLINICAL RELEVANCE: Class III therapy using extraoral face mask anchorage is effective for maxillary protraction. The recently discussed new protocols potentially improve this treatment.

Perception of esthetic orthodontic appliances: An eye tracking and cross-sectional study.

OBJECTIVE: To evaluate the perception of esthetic orthodontic appliances by means of eye-tracking measurements and survey investigation. MATERIALS AND METHODS: En face and close-up images with different orthodontic appliances (aligner appliance [a], aligner appliance and attachments [b], lingual appliance [c], ceramic brackets [d], no appliance [e; control]) were shown to 140 participants. Eye movement and gaze direction was recorded by eye-tracking system. For different anatomical areas and areas of the appliances, time to first fixation and total fixation time were recorded. The questions included in a visual analog scale regarding individual sentiency were answered by the participants. RESULTS: For all groups, the anatomical landmarks were inspected in the following order: (1) eyes, (2) mouth, (3) nose, (4) hair, and (5) ears. Only in group d, first fixation was on the mouth region (1.10 ± 1.05 seconds). All appliances except the lingual appliance (1.87 ± 1.31 seconds) resulted in a longer fixation on the mouth area (a, 2.97 ± 1.32 seconds; b, 3.35 ± 1.38 seconds; d, 3.29 ± 1.36 seconds). For close-up pictures, the fastest (0.58 seconds) and longest (3.14 seconds) fixation was found for group d, followed by group b (1.02 seconds/2.3 seconds), group a (2.57 seconds/0.83 seconds), and group c (3.28 seconds/0.05 seconds). Visual analog scale scoring of questions on visibility were consistent with eye-tracking measurements. With increasing visibility, the feeling of esthetic impairment was considered higher. CONCLUSIONS: Lingual orthodontic appliances do not change how the face is perceived. Other esthetic orthodontic appliances may change the pattern of facial inspection and are different in subjective perception.

The effect of debonding and/or bleaching on enamel color - an in-vitro study.

AIM: There are various studies in the literature on bonding brackets to bleached teeth and on the effect of bleaching material on the color of compomers. The purpose of this study was to investigate changes in tooth color depending on the process of bonding - debonding and/or bleaching. MATERIAL AND METHODS: Ninety crowns of lower bovine permanent incisors were divided into nine subgroups. Three bonding materials (chemical, light- and pressure-cured) and three bleaching materials (15% CP, 35% CP, or 38% HP) were applied to the teeth, whereby each tooth was divided into quarters: untreated, bleached only, bonded-debonded only, and bleached after a bonding-debonding procedure. The Easyshade spectrophotometer was used to determine CIELCh coordinates (lightness, color, and hue) three times for each area. The areas' differences in color were expressed as the Euclidian distance DeltaE. Four examiners (two orthodontists and two dentists) rated each tooth concerning color differences in the four areas. The data collected was subjected to the sign and Wilcoxon or the Kruskal-Wallis and Mann-Whitney U tests using the SPSS 12.0 program. RESULTS: Examiners found significant differences between those areas with and those without bleaching within each group of specimens (p < 0.05), but there were no differences concerning the bonding and debonding procedures (p > 0.05). Furthermore, digital tooth-shade measurements revealed no statistically-significant group-associated differences between those areas treated with bonding material and those not so treated, nor between bonded and debonded areas (p > 0.05). Nor did we observe any statistically-significant differences between bleached areas and those areas bleached after bonding and debonding procedures (p > 0.05). CONCLUSION: The processes of bonding and debonding alone do not seem to have any statistically-significant influence on the tooth color of bovine enamel using these testing materials, nor does the subsequent bleaching procedure.

The discoloring effects of food on the color stability of esthetic brackets--an in-vitro study.

AIM: The purpose of this study was to investigate the discoloring effect of certain foods on the color stability of esthetic brackets made of different materials. MATERIAL AND METHODS: Ten specimens of six different tooth-colored brackets were immersed for 10 days at 37 degrees C in various solutions (de-ionized water, tea, coffee, red wine, orange juice, curry and cress) or exposed to accelerated photo-aging (150 KJ/ m(2), 340 nm). Using the Easyshade device, the brackets were analyzed at the beginning of the experiment and after ultrasound-cleaning daily thereafter for ten days according to CIELCh coordinates lightness, chroma and hue. Our results were evaluated using the SPSS-12.0 statistical program and subjected to the Kruskal-Wallis and/or Mann-Whitney U tests. RESULTS: The results can be divided into three types of reactions. The brackets exposed to UV light, cress or orange juice showed no visible discoloration. The measured color differences remained in the same range as the measurements for brackets in the control group. All brackets immersed in red wine, tea or coffee showed similar reactions, with a sharp increase in discoloration after 5 days (corresponding to high consumption). In the curry solution, the brackets made of polyoxymethylene became immediately discolored; all other bracket types showed no visible reaction. CONCLUSIONS: This in-vitro test can only simulate the actual intra-oral situation, but the results seem to demonstrate that the consumption of certain foods greatly influences to what extent the color of tooth-colored brackets changes.

[Tooth shape and color as criteria for or against orthodontic space closure in case of a missing lateral incisor].

AIM: The aim of this study was to examine the esthetic parameters that are applied, more or less unconsciously, in deciding for or against orthodontic space closure in the case of aplasia or traumatic loss of lateral incisors. MATERIALS AND METHOD: The width-height index for teeth 13 to 23 was measured on 200 dental students. The VITA Easyshade system was used to determine the components of the tooth color (L, C, h) and to identify differences between each tooth. Eight investigators subjectively assessed digital photographs of the subjects, opting for or against space closure. The Spearman correlation coefficients were calculated for the parameters measured. RESULTS: A comparison of the parameters showed that not one factor alone was responsible for the decision for or against space closure for esthetic reasons. Orthodontists were more likely to favor space closure when the canine was slightly wider and had a less pointed shape and the differences were very small between canine and central incisor in terms of hue, chroma, and lightness. CONCLUSION: We observed that the subjective decision on the esthetic aspects of space closure correlates closely with the objective criteria.

Analyzing the teeth next to the alveolar cleft: Examination and treatment proposal prior to bone grafting based on three-dimensional versus two-dimensional diagnosis-A diagnostic study.

PURPOSE: The objective was to evaluate the diagnostic and prognostic value of three-dimensional (3D) cone beam computed tomography (CBCT) on information about the cleft and alignment of cleft neighboring teeth. MATERIALS AND METHODS: Panoramic X-rays, small-volume CBCTs, and study casts of 20 patients with a total of 22 alveolar clefts were analyzed prior to secondary bone grafting. Six maxillofacial surgeons and 6 orthodontists rated the following parameters: visibility of alveolar cleft expansion, position and probability of alignment of cleft neighbored teeth. Two-dimensional (2D) X-rays and casts were rated first; CBCT and casts followed at least 4 weeks later. Radiologic bone height in the region of the former alveolar cleft, as well as alignment and reasons for nonalignment of cleft neighbored teeth, were recorded 4 years later. RESULTS: The rate of proper proposals regarding the real treatment outcome using 2D- or 3D-material did not differ statistically. Although 5%-45% of the proposals were changed when using 3D instead of 2D records, Fleiss multirater kappas showed no essential differences. Raters' profession and experience had no influence on the rate of correct proposals. CONCLUSION: In orthodontics, small-volume CBCT may be justified only as supplement to a routine panoramic X-ray, and only in selected cases or for surgical preparation.

Cholesteatoma of the hypotympanum in a patient with Treacher Collins syndrome.

In the present article we report a cholesteatoma of the hypotympanum extending to the jugular foramen in a 16-year-old male with Treacher Collins syndrome. Preoperative imaging excluded jugular paraganglioma and set the diagnosis of cholesteatoma. We discuss the operative treatment via a large hypotympanotomy and creation of an open hypotympanic cavity. To the authors' knowledge this is the first description of hypotympanal cholesteatoma with such an extension, being treated through this approach.

Influence of osteotomy procedure and surgical experience on early complications after orthognathic surgery in the mandible.

INTRODUCTION: This study evaluated the influence of osteotomy procedure and surgical experience on early complication rates following orthognathic surgery in the mandible. MATERIALS AND METHODS: In a retrospective study, patients who underwent a mandibular osteotomy (Obwegeser-Dal Pont (ODP) and Hunsuk-Epker (HE)) were included. Incidence of "bad splits", "bleeding episodes", "delayed wound healing", "failed osteosynthesis" and "nerve lesions" at 2 months post-operatively were recorded. Surgical experience was classified as: beginner (<10), intermediate (10-40) and expert (>40). Complications were correlated to the surgical approach and the experience level of the surgeon. RESULTS: 400 patients were included. 200 underwent a bimaxillary approach. 186 patients were operated using the ODP technique, 214 according to HE. Multivariate analysis confirmed significantly more unwanted fractures and bleeding events for ODP when compared to HE (p = 0.28, p = 0.003). Experienced surgeons had more osteosynthesis failures (0.047) and significantly more nerve lesions than the other groups (p = 0.01). DISCUSSION: The HE osteotomy showed a more reliable fracture mechanism with less relevant bleeding episodes. Differences between the surgeons of varying training status were marginal with exception of a higher rate of osteosynthesis failure and temporary hypoesthesia in the experienced group.

Digital 3D image of bimaxillary casts connected by a vestibular scan.

AIM: The task of three-dimensionally aligning digital images of scans taken from maxillary and mandibular casts can be accomplished by scanning an interocclusal record, but vestibular scanning is also an option. The present study addressed whether this latter technique is precise enough to be used in orthodontic practice. MATERIALS AND METHODS: A total of 10 pairs of casts representing different types of tooth and jaw malposition were scanned with a photo-optical scanner (Activity 102; Smart Optics, Bochum, Germany). After obtaining detailed single scans of each upper and lower jaw, each pair of casts was rigidly aligned with instant glue. Subsequently, three vestibular scans were taken and were then merged with the single-jaw scans to form virtual bimaxillary models. These virtual models were superimposed with each other and analyzed, using the structures of the mandible as constant and documenting the highest occlusal and vestibular deviations measured on each maxillary tooth or gingival region. Descriptive analysis and a mixed linear model were performed with SPSS and SAS. RESULTS: The greatest deviations between the virtual bimaxillary models averaged 37 ± 28 µm. No significant differences were seen between tooth sites along the dental arch, dentate versus edentulous sites, or occlusal versus vestibular surfaces. The mean of the greatest deviations between repeated scans were found to be 28 ± 14 µm (vestibular scans) and 15 ± 8 µm (single-jaw scans). CONCLUSION: The presented approach of generating bimaxillary study models in a virtual environment with the help of vestibular scans meets the precision requirements for use in orthodontics and can be employed in further studies.

Influence of patient age and experience of the surgeon on early complications after surgical closure of the cleft palate--a retrospective cohort study.

Comparative studies on timing of palatoplasty are rare. The aim of this retrospective cohort study was to compare the influence of early (<14 months) and later (>14 months) one-step closure of the soft and hard palate on early complications. All non-syndromic patients from 1999 to 2009 were included; 6-14 months n = 41 and 15-24 months n = 53. Each palatoplasty was performed as a single-step procedure using bipedicled flaps by a team of two Maxillofacial Surgeons either supervising or operating. The surgeon was rated as "non-experienced" when having performed less than 10 palatoplasties under supervision. Main outcome variable is the occurrence of residual fistula. Fistula occurred in four (4.5%) of the patients. In the multivariate model with respect to the occurrence of fistula neither age, leucocyte count, duration of surgery, nor experience of the surgeon showed a significant influence on the occurrence of a fistula. Only reduced weight contributed to a significantly higher risk of post-operative fistula. In conclusion patient age, experience of surgeon, and duration of surgery had no influence on the early outcome. High leucocyte count had a tendency for and reduced weight had a significant influence on fistula occurrence. Long-term outcome on speech development and maxillary growth have to be collected.

Impacted upper canines: examination and treatment proposal based on 3D versus 2D diagnosis.

AIM: The purpose of this diagnostic cross-over study was to evaluate whether three-dimensional (3D) diagnostics (cone-beam computed tomography, CBCT) was superior to two-dimensional (2D) diagnostics (panoramic X-ray, OPG) in patients with impacted upper canines for assessing their position and the probability of their alignment. MATERIALS AND METHODS: Panoramic X-rays, CBCTs, and study casts of 21 patients with a total of 29 impacted maxillary canines were analyzed. Patients with syndromes or tooth aplasias were excluded. A total of 26 dentists of various specialist disciplines rated different parameters, such as canine position and their probability of alignment as well as their relation to and resorption of adjacent teeth. 2D X-rays and study casts were rated first; then 3D images and casts were evaluated at least 2 weeks later. The actual level of displacement was defined by two trained examiners and labeled as the master finding, according to modified criteria established by Ericson and Kurol (1988). RESULTS: In 64% of all patients, canine position was assessed concordantly in 2D and 3D images. 2D assessments were in slight agreement (κ = 0.374), while 3D ratings were in good agreement with the master findings (κ = 0.714). Two-thirds of the canines' apical regions were judged identifiable in 2D and 3D images; more than 1/4 of the canines' apices were not identifiable in 2D images, but were identifiable in 3D images. The diagnosis of lateral incisor root resorption in the CBCT agreed well with the master finding (κ = 0.634), but examiners overlooked slight resorption in 20% of the patients. In 82% of the patients teeth, treatment suggestions (orthodontic alignment or surgical removal) were the same for 2D and 3D images. Canine inclination visible in the panoramic X-rays was the most important factor influencing the treatment proposal. CONCLUSION: Small volume CBCT may be justified as a supplement to a routine panoramic X-ray in the following cases: when canine inclination in the panoramic X-ray exceeds 30°, when root resorption of adjacent teeth is suspected, and/or when the canine apex is not clearly discernible in the panoramic X-ray, implying dilaceration of the canine root. We intend to validate the results of this study in a clinical trial.

Invisalign® treatment in the anterior region: were the predicted tooth movements achieved?

OBJECTIVE: Based on our previous pilot study, the objective of this extended study was to compare (a) casts to their corresponding digital ClinCheck® models at baseline and (b) the tooth movement achieved at the end of aligner therapy (Invisalign®) to the predicted movement in the anterior region. MATERIALS AND METHODS: Pre- and post-treatment casts as well as initial and final ClinChecks® models of 50 patients (15-63 years of age) were analyzed. All patients were treated with Invisalign® (Align Technology, Santa Clara, CA, USA). Evaluated parameters were: upper/lower anterior arch length and intercanine distance, overjet, overbite, dental midline shift, and the irregularity index according to Little. The comparison achieved/predicted tooth movement was tested for equivalence [adjusted 98.57% confidence interval (- 1.00; + 1.00)]. RESULTS: Before treatment the anterior crowding, according to Little, was on average 5.39 mm (minimum 1.50 mm, maximum 14.50 mm) in the upper dentition and 5.96 mm (minimum 2.00 mm, maximum 11.50 mm) in the lower dentition. After treatment the values were reduced to 1.57 mm (minimum 0 mm, maximum 4.5 mm) in the maxilla and 0.82 mm (minimum 0 mm, maximum 2.50 mm) in the mandible. We found slight deviations between pretreatment casts and initialClinCheck® ranging on average from -0.08 mm (SD ± 0.29) for the overjet and up to -0.28 mm (SD ± 0.46) for the upper anterior arch length. The difference between achieved/predicted tooth movements ranged on average from 0.01 mm (SD ± 0.48) for the lower anterior arch length, up to 0.7 mm (SD ± 0.87) for the overbite. All parameters were significantly equivalent except for the overbite (-1.02; -0.39). CONCLUSION: Performed with aligners (Invisalign®), the resolvement of the partly severe anterior crowding was successfully accomplished. Resolving lower anterior crowding by protrusion of the anterior teeth (i.e., enlargement of the anterior arch length) seems well predictable. The initial ClinCheck® models provided high accuracy compared to the initial casts. The achieved tooth movement was in concordance with the predicted movement for all parameters, except for the overbite.

Long-term effects of traumatic injuries to incisors and periodontal tissues during childhood: a retrospective study.

AIM: The purpose of this study was to investigate the incidence of dentoalveolar growth disturbances, loss of teeth and esthetic impairment after the end of growth following traumatic injuries to incisors and periodontal tissues during childhood. MATERIALS AND METHODS: 41 patients having sustained dentoalveolar trauma before age 10 and who were now at least aged 16 years, and a total of 68 traumatized teeth were documented by clinical examination, dental casts and photographs. We determined the three-dimensional position of the traumatized teeth on the casts, as well as the traumatized teeth's pulp sensibility, percussive sound and sensitivity, shape and color. RESULTS: 82% of the traumatized teeth were in the upper dentition. 45% of the traumatized teeth experienced subluxation, nearly 30% luxation, 16% avulsion. At the time of the follow-up examination (mean 17.0 years post-trauma), 57% of the traumatized teeth were still in situ. Immediately after trauma 7.4% of the teeth were lost; up to 16 years post-trauma 35.6% of the teeth were lost because of failed root canal filling, root resorption or ankylosis. We observed no functional deviations. Dentoalveolar growth disturbances were rare. Three teeth were markedly discolored. CONCLUSION: Following dentoalveolar trauma during childhood, negative effects on growth, function and esthetics can be minimized by timely interdisciplinary treatment and by follow-up controls until the end of growth to achieve an outcome satisfying both the patient and clinician.

3D analysis of condylar position after sagittal split osteotomy of the mandible in mono- and bimaxillary orthognathic surgery - a methodology study in 18 patients.

OBJECTIVES: This study analyzes the condylar position with intercondylar distance and angle after sagittal split osteotomy in mono- and bimaxillary orthognathic surgery applying cone-beam computed tomography (CBCT) images before and after surgery. MATERIALS AND METHODS: Data of 18 patients, ten males (mean age 28 years) and eight females (mean age 26 years) undergoing the described surgery between 2008 and 2009 were analyzed. CBCT scans were performed with the KaVo 3DeXam (KaVo, Biberach/ Riß, Germany) (identical with the iCAT scan device) before and after surgery. The exported DICOM data were analyzed with ImageJ morphometry software. Patients were also asked about TMJ problems. The two-tailed t test was used and significance was set at a p value less than p = 0.05. RESULTS: There was no significant difference between the pre- and postoperative distances between condylar centers (mean difference: 1 mm) (p = 0.69) and intercondylar angle (mean difference: 6.6°) (p = 0.27). CONCLUSIONS: CBCT is a novel imaging technique appropriate for detailed and three-dimensional analysis of the condylar position in orthognathic surgery. Available freeware analysis software can be applied for metrical measurements. Our cases showed no significant changes of condylar position immediately after surgery without intraoperative condylar fixation.

Combined treatment of open bite - long-term evaluation and relapse factors.

BACKGROUND AND OBJECTIVE: Some patients with open bite who have been treated with combined fixed orthodontic appliances and bimaxillary osteotomy relapse in the vertical dimension after the end of treatment following initially successful correction of the vertical dimension. The aim of this study was to identify those parameters that raise the tendency to relapse. MATERIALS AND METHODS: Nineteen patients who underwent combined treatment using fixed orthodontic appliances and bimaxillary osteotomy due to open bite (overbite < 0 mm), were examined and documented at least 2 years after surgery. Pre- and post-orthodontic and pre- and post-operative study models and lateral head films were analyzed. Overbite reduction after the end of treatment was considered as relapse. RESULTS: In our study cohort, the appearance of relapse in the vertical correlated with the enlargement of Björk's sum angle (odds ratio 10.7) and Jarabak's ratio (odds ratio 7) by means of surgery, as well as with dysfunctional habits persisting after treatment such as mouth breathing (odds ratio 12.5) and a visceral swallowing pattern (odds ratio 8.3). The existence at baseline of isolated anteinclination of the anterior maxilla or isolated steep inclination of the mandible also made vertical relapse more probable (odds ratio 7.5). CONCLUSION: Particularly deserving of attention during the combined interdisciplinary treatment of patients with open bite are the achieved reduction in posterior facial height by surgical posterior impaction of the maxilla, as well as correction of dysfunctional parameters during swallowing and breathing.