Functional and social discomfort during orthodontic treatment--effects on compliance and prediction of patients' adaptation by personality variables.

During the course of treatment orthodontic patients frequently endure a number of functional complaints and are anxious about their appearance. The aims of this longitudinal study were to follow the progress of patients' adaptation to discomfort, to elucidate the putative relationship between the type of appliance worn and functional and social discomfort experienced, to study potential predictability by their attitude to treatment and to evaluate the effects of discomfort as predictors of patients' compliance. Eighty-four patients undergoing either removable, functional, or fixed appliance treatment monitored their complaints during the first 7 days of treatment and rated them retrospectively 14 days, and 3 and 6 months after appliance insertion. The most frequent complaints were impaired speech, impaired swallowing, feeling of oral constraint and lack of confidence in public. A significant reduction in the number of complaints was observed between 2 and 7 days after insertion of the appliance. No further differences were revealed after longer periods of appliance wear. The type of appliance had an effect on impaired speech and swallowing. Patients' expectations of favourable treatment performance and appreciation of dental aesthetics were predictive of reported feeling of oral constraint and lack of confidence in public. There was a relationship between the complaints and acceptance of the appliance, as well as between lack of confidence in public and compliance with treatment. The results of this study highlight the importance of patients' attitudes to treatment and of functional and social discomfort associated with appliance wear for the theory and practice of the management of orthodontic patients, and the necessity for early intervention by clinicians.

Efficacy of protection by latex gloves during orthodontic therapy.

The wearing of gloves during orthodontic or dental treatment is generally indicated for reasons of hygiene and protection against infection. This study was aimed at determining the extent and localization of perforations caused by the various orthodontic treatment techniques and interrupting the infection barrier. The impermeability was tested by means of a water retention test according to European standard EN 455, Part 1, performed on 1600 Centramed (Centramed, Koblenz), Tekmedic and SafeEx non-sterile disposable latex gloves (both by Safe Med, Switzerland) and Safe Gan latex gloves with an additional acrylate coating (also by Safe Med). The perforation rate in unused gloves was between 0.5% and 7.5%, rising on average to 11% with increasing use. 36% of the total number of lesions resulted from handling removable appliances, and 57% from handling fixed appliances, especially when replacing arch wires and elastics. Most lesions were in the thumb, index finger and palm region. Only 18% of the defects were noticed by the dentists themselves. The gloves worn by beginners in their first year of postgraduate orthodontic training had about twice as many defects as those worn by qualified orthodontists. When patients with an increased risk of infection are to be treated, additional hand disinfection measures should be taken and 2 pairs of gloves worn in view of the relatively unreliable protection offered by commercially available latex gloves.

Relationship between patient discomfort, appliance acceptance and compliance in orthodontic therapy.

Orthodontic treatment is occasionally a discomfort to patients, due to pain or functional restrictions. In this context, several retrospectively planned studies were performed in the 1980s, but correlations between different aspects of patient discomfort were not investigated. The present study aimed at examining and structuring the psychogenic dimensions of patient discomfort. Furthermore, the impact of the patient's attitude on the intensity of discomfort was to be evaluated in addition to the influences of appliance therapy. The study was performed with 67 patients aged from 9 to 32 years. Prior to insertion of a new appliance, psychogenic scales reflecting their attitude towards orthodontic therapy were submitted to them. They were instructed to keep a discomfort log during the first 7 days after insertion. After 6 months they were given lists for retrospective assessment of discomfort and an appliance-acceptance scale to be filled in. At the same time, the respective orthodontist assessed his patient's compliance on a cooperation scale. The factor analysis revealed 3 levels of patient discomfort: feelings of tension, functional restrictions and aversion to wearing an orthodontic appliance in public. Appliance acceptance after 6 months could be predicted from the attitude towards treatment and the experienced discomfort. Patient compliance also correlated with these factors, so that causal flow diagrams of the investigated variables could be produced. Giving detailed information on any discomfort occurring and explaining how to reduce or eliminate it are vital factors in good treatment cooperation.

Proliferative response of cells of the dentogingival junction to mechanical stimulation.

The aim of this research was to study the proliferative response of junctional epithelium (JE) and gingival connective tissue (GCT) to mechanical stimulation in vivo with regard to the potential occurrence of apical migration of JE and loss of GCT attachment during orthodontic tooth movement. Elastic bands were inserted between the maxillary first and second molars of male rats aged 8 weeks, which were pulse-labelled with 3H-thymidine and subsequently killed in groups, together with labelled control animals (a total of 98 rats) after periods of 1-168 hours. Autoradiographs were prepared from plastic mesiodistal sections, and parameters of cell proliferation for JE and GCT of the papilla between the second and third molars were determined. Although the distance between the apical limit of JE and the most coronal periodontal ligament (PDL) fibres decreased on the pressure and increased on the tension sides of mechanically stimulated animals, the total cross-sectional area of JE remained unchanged compared with controls. In the basal and suprabasal layers of JE, cell proliferation was reduced on the pressure side and showed no change on the tension side. In the apical JE compartments on both sides, mechanical stressing resulted in lower proliferative activity. Cell proliferation in GCT adjacent to JE in stimulated animals did not differ from the corresponding controls. JE rapidly adapted to mechanical stimulation by means of differential local adjustments of cell proliferation without an occurrence of apical migration or hyperplasia. GCT cells in the vicinity of JE maintained their steady-state proliferative activity. These results do not support the concept that orthodontic tooth movement might per se have detrimental effects on the stability of the dentogingival junction.

Pain and discomfort during orthodontic treatment: causative factors and effects on compliance.

Orthodontic patients experience pain and discomfort to a varying degree during the course of treatment. The aims of the present investigation were to follow the progress of adaptation after insertion of new appliances and to study the relationships between the type of appliance worn and pain or discomfort experienced, between pain sensations and attitude toward the treatment and their effects on patients' compliance. Pain and discomfort experienced by 84 patients undergoing orthodontic treatment, their attitude toward the treatment, and compliance were assessed 7 days, 14 days, 6 weeks, 3 months, and 6 months after appliance insertion, using specially designed protocols, questionnaires, and rating scales. Evaluation of the results showed that an adaptation to pain and discomfort occurred during the first 3 to 5 days after placement of the appliance. The severity of pain and discomfort experienced by the patients wearing functional or fixed appliances was significantly higher than by those treated with upper and/or lower removable plates. Patients who had higher personal perception of the severity of their malocclusion and displayed attitudes characteristic for internal control orientation according to the so-called locus of control theory, seemed to adapt faster and have less pain. The results of this study also indicate that acceptance of orthodontic appliances and treatment in general may be predicted by the amount of initial pain and discomfort experienced.

A comparative assessment of acceptance of different types of functional appliances.

Patients' acceptance of an orthodontic appliance may influence compliance and thus contribute to a successful outcome of treatment. The aim of this study was to assess the influence of shape and design of different types of functional appliances on their acceptance by patients. For each of 10 adult volunteer subjects employed in the study eight different functional appliances were fabricated which had a varying extension of the resin base and amount of interocclusal opening. Effects of appliances on speech, initial acceptance, and acceptance after wearing were assessed by means of standardized tests. Amongst the appliances tested the bionator, functional corrector FR-I and elastic open activator showed the highest acceptance by the test subjects. The results of the study indicate that there is a considerable difference in acceptance of various types of functional appliances.

An experimental study of the esthetic effect of facial profiles.

In this study good-looking "male" and "female" as well as ugly facial profiles were shaped by 104 lay persons using an especially constructed device according to specific instructions. These profiles were photographed and subsequently evaluated using a series of parameters from soft tissue profile analyses. Although some significant mean value differences were found between the good-looking and ugly profile variants, they were not substantial. In contrast, markedly significant differences were revealed between the variances of all variables. In some instances the variance of the ugly profiles was more than 3 to 4 times higher than that of the good-looking profiles. These findings were convincingly confirmed when statistical distribution of the data was established and compared. This implies that perception of beauty is associated with regularity of facial features and is conveyed by measurement values which are located close to the mean. Ugliness is associated with extreme deviations from the latter in either direction. Apart from the facial proportions, the degree of convexity or concavity of facial profile and their sequence seem to be important for the esthetic effects. "Male" profiles in contrast to "female" profiles exhibited more conspicuous facial features such as pronounced convexity and concavity.

Study of psychosocial aspects of adult orthodontic treatment.

A semistandardized questionnaire was administered to adult orthodontic patients to gain insight into their motives for seeking treatment and their experience during treatment. The data collected from 60 patients aged 18 to 52 years were used for descriptive statistics and calculation of correlations. The results indicate that apart from objective and immediately comprehensible reasons for certain behavioral patterns, ideas influencing emotional life may have an important effect on attitudes toward treatment. The results may be useful for both initial consultation and patient management and guidance during treatment.

A method of measuring the apical base.

The maxillary and mandibular apical base areas were measured, using a gnathograph, on the study casts of 156 adults and children representing Class II division 1, Class II division 2 and Class III malocclusions. There were significant differences between the groups at each age. The maxillary apical base areas tended to be smaller for the adults than for the children in all three occlusal classes. By contrast, the mandibular apical base areas tended to be larger for the adults than for the children, except in Class II division 1 malocclusion. Following a logarithmic transformation to stabilize the variance, regression lines were fitted to relate the size of the maxillary and mandibular apical bases to one another, for the malocclusion groups within each age group. The method gives additional information regarding the degree of apical base discrepancy in a given case, but more work is required before it can be used as a diagnostic tool.

A holographic study of variations in bone deformations resulting from different headgear forces in a macerated human skull.

The effects of headgear on maxillary displacement and the resulting growth modifications are not completely understood, especially regarding the complex relationships between initial and secondary skeletal reactions on one hand and the influence of the direction and magnitude of the applied force on the other. The aim of the present investigation was to study, by means of holographic interferometry, the initial bone displacement occurring in response to headgear traction applied at different force magnitudes and in different directions. Orthopedic forces of 560 grams and orthodontic forces of 354 grams were stimulated on a macerated human skull. The forces came from from high-, straight-, and low-pull headgear traction directed above, through, and below the center of resistance of the maxillary first permanent molars. Immediate skeletal changes were recorded by laser holography. Initial displacements of the maxilla and zygomatic arch in both horizontal and vertical planes were evaluated on frontal and lateral holograms. In most cases, both force magnitudes caused substantial displacements in both planes, albeit to different extents. Complex bending, and rotational, translational, and relative displacements were observed. The direction of displacement did not strictly coincide with that of the applied force. The results of this study indicate that both orthodontic and orthopedic headgear traction may lead to complex initial three-dimensional skeletal displacement in directions not always corresponding with the direction of the applied force.

[A holographic study to demonstrate the initial displacements of a macerated human skull under the influence of the orthodontic force from headgear with traction in different directions]. / Holographische Untersuchung zur Darstellung initialer Verformungen eines mazerierten menschlichen Schädels unter der Einwirkung einer orthopädischen Kraft durch einen Headgear mit verschiedenen Zugrichtungen.

The phenomena of maxillary displacement and the subsequent growth modifications which result from the application of orthopedic headgear traction are very complex and not yet completely understood. The aim of this study was to investigate with the help of holographic interferometry the influence of the headgear's differing traction directions on the initial bone displacement in the maxillary complex. 560 g high, straight, and low pull headgear traction exerted above, through, and below the center of resistance of the upper first permanent molars was simulated on a macerated human skull and skeletal changes were recorded by laser holography as they occurred. On the basis of the frontal and lateral holograms thus obtained, the initial displacement of the maxilla, zygoma, and zygomatic arch in both horizontal and vertical planes was evaluated. Substantial displacements in various parts of the studied structures, displacements such as bending, relative deformation, rotation, and translation, were detected, and, further, the direction of this complex displacement often deviated from the direction of the influencing force. The results obtained by this study indicate that the initial 3-dimensional skeletal displacements brought about by the headgear are very complex. The clinical implication is that they do not always correspond with the direction intended by the force applied.

[An in-vitro study of 2 resins used in orthodontics for their cell toxicity]. / Eine In-vitro-Untersuchung zweier in der Kieferorthopädie verwendeter Kunststoffe auf Zelltoxizität.

The aim of this study was to examine in vitro cell compatibility of the orthodontic base resins Orthocryl (Dentaurum) and Wil-o-dont (Wilde) using the method described by Heidemann and Lampert (1980). The acute local nonspecific cytotoxicity of these materials and that of their individual components were evaluated. Used were both a qualitative microscopic assessment of cytopathological changes occurring in human gingival fibroblasts cultured along side the specimens and a semiquantitative assessment of the zones of inhibited cell growth around the specimens. Whereas Orthocryl and its components exhibited no toxic influence on the growth of the cultured cells, substantial cytotoxicity was observed in the tests of Wil-o-dont. The monomer and the adhesive component of this resin were found to be particularly toxic under the conditions tested. On the basis of the results of the study Wil-o-dont can not be given a clean bill of health in relation to the cytotoxicity of the product.

Theoretical approaches to behavior change in myofunctional therapy.

The effectiveness of myofunctional therapy depends not only on the quality of the individual exercises but also considerably on the patient's compliance. In this paper, factors are described which may decisively influence patients motivation to cooperate during treatment. Based on experience in dealing with patients, clinical studies and psychological knowledge, theoretical approaches to patient motivation are discussed, namely aspects of verbal communication, control, reward, behavior agreement as well as verbal self-control and self-reward.

[A dental arch index related to tooth size and facial breadth]. / Ein zahngrössen- und gesichtsbreitenbezogener Zahnbogenindex.

Taking as its starting point the often postulated criticism of Pont's Index, the intent of the study was to develop a diagnostic procedure which took into consideration the objection that the Pont Index doesn't take the shape of the patient's skull into consideration. On the basis of the data obtained from the models and anthropological measurements of 50 adult subjects with fairly eugnathic dentition, the first step was to follow Pont and study which skull size exhibited the highest correlation to the posterior dental arch. Of all the relevant sizes the zygomatic arch width exhibited the highest correlation. Reference values for the posterior dental arch width, which were obtained with the help of regression analysis, which took into consideration both the total upper incisor width and zygomatic arch width as variables, were then established. These reference values were conclusively shown to have the best prognostic value. From this it can be concluded that a comprehensive orthodontic diagnosis should include an improved assessment of dental arch width.

On the prediction of dentist-evaluated patient compliance in orthodontics.

The aim of the present study was to determine to what degree social and psychological patient variables can predict orthodontic co-operation evaluated by dentists 3 and 6 months after the beginning of treatment. The subjects were 94 patients from seven orthodontic practices. They received a questionnaire with four subscales: impulsiveness, dominance, anxiety, and orthodontic attitudes. Compliance was assessed by an 11-item instrument based on the studies of Slakter et al. (1980). None of the social indices could predict co-operation, but the psychological scales for orthodontic attitudes, impulsiveness and dominance showed a significant relationship to later co-operation. The combination of all psychological variables (regression equation) could explain co-operation 3 months later to 12.1 per cent and to 16.8 per cent 6 months later. The implications for psychological guidance in orthodontics and future research are discussed.

Relations between verbal behavior of the orthodontist and communicative cooperation of the patient in regular orthodontic visits.

A study of interrelationships between orthodontist and patient communication characteristics on the basis of audiotape recordings is reported. The subjects were 66 patients from an orthodontic outpatient clinic who were treated by seven orthodontists. Strong relationships (partial correlations) were found between clinicians encouraging behavior (listener signals and symmetrical answering) and patient communicative cooperation (speech volume, detailed answering, questions, initiatives); whereas orthodontists guiding behavior showed lower correlations, only the clinicians' direct questions were significantly related to patient participation. For communication content, relations to patient activity depended on how strongly orthodontists discussed social or therapy topics. Discussion characteristics of both parties were not related to the patient's age, sex, and duration of therapy. However, patient communication differed with the personality of the dentist. Results are discussed with reference to literature, orthodontic consulting practice, and future research.

[Elemental analytical and quantitative morphometric determination of the synthetic resin residues and enamel avulsion after the removal of metal brackets]. / Elementanalytische und quantitativmorphometrische Bestimmung von Kunststoffresten und Schmelzausrissen nach der Abnahme von Metallbrackets.

A number of clinical and experimental studies were performed to assess the quality of the enamel-adhesive-bracket bond. The aim was to present a combined method that enables the investigator both to examine the surface of metal brackets quantitative-morphometrically and to detect the presence of enamel particles. To this end, 38 metal brackets were examined in the scanning electron microscope. An EDAX-detecting unit was used to analyze morphologically conspicuous structures and identified them as enamel particles. The extent of adhesive remnants and enamel particles was quantified using the image analysis system IBAS. In 24 brackets (53%) bonding adhesive residue was found on the bracket base. In 18 brackets (47%) enamel particles were identified on the adhesive-bearing brackets. This method is easier to carry out and enables a more accurate quantification of enamel particles than the Adhesive Remnant Index. Since it can be applied universally to examine recommended improvements to adhesive technique, it facilitates their assessment.

[A comparative study of the possibility of reducing the dosage in lateral teleradiographs]. / Vergleichende Untersuchung zur Möglichkeit der Dosisreduzierung von Fernröntgenseitenaufnahmen.

Thanks to their capability for post-processing of image data, the digital radiological techniques introduced from 1970 onwards permit dose reduction with no loss of clinical information. The aim of this study was to establish the extent of possible dose reduction in orthodontic lateral cephalography. For this purpose, lateral cephalograms of a head phantom taken with varying radiation doses (5 to 150 mAs, constant 70 kV) were evaluated. The evaluations of ten judges were compared statistically. Conventional lateral cephalograms showed a statistically proven superiority of a number of exposure parameters for the sagittal and vertical localisation of reference points. This correlated with the radiological density of the structures. In contrast to the conventional technique, the reference points in all images obtained by digital luminescence radiography showed no such tendency. Digital luminescence thus meets the clinical need to reduce radiation dose (to about 20% of the usual dose) while providing no less diagnostic information.

[The demonstration of cellular reactions in the temporomandibular condylar cartilage by NMR microscopy. The basic research for high-resolution NMR tomography of the temporomandibular joint]. / Der Nachweis zellulärer Reaktionen im kondylären Kiefergelenkknorpel mittels NMR-Mikroskopie. Grundlagenuntersuchungen für eine hochaufgelöste Kernspintomographie am Kiefergelenk.

The regional resolution of modern imaging methods is not good enough to clinically objectify changes to the cartilage of the temporomandibular joint, for example in functional orthodontic treatment. NMR microscopic studies of an intact temporomandibular joint preparation were done experimentally in the domestic pig on the basis of 1H-NMR relaxometric measurements in specimens of condylar cartilage. We succeeded in representing the cartilage of the temporomandibular joint down to the cellular level, and in demonstrating regeneration processes as a late sequela of surgery on the temporomandibular joint. The results are discussed with respect to their importance for future high-resolution magnetic resonance imaging of the temporomandibular joint.

Morphological cephalometric differences between two European populations.

Earlier research in craniofacial morphology of the inhabitants of Mainz (Germany) and Zagreb (Croatia), who represent the populations of wider areas, have shown some roentgen-cephalometric differences. The aim of this study is to determine the craniofacial morphologic differences of these populations in three dimensions. The sample consists of 200 adult examinees, male and female respectively, inhabiting the mentioned areas. The sample has been chosen so that the examinees with prominent craniofacial anomalies have been excluded. Twenty three craniofacial parameters with the usual anthropometric instruments have been measured. The data have been processed by using elementary descriptive statistics and discriminant analysis. The results have shown that in Mainz examinees longer and narrower heads and higher faces in comparison with Zagreb examinees, predominate. Significant differences in forehead widths and bipupilar distances have been found.