Effect of protraction facemask on the temporomandibular joint: a systematic review.

BACKGROUND: The aim of this study was to assess the influence of protraction facemask (PFM) on temporomandibular joint (TMJ) of skeletal Class III malocclusion patients. METHOD: Literature searches were carried out electronically in five English and three Chinese databases (Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, Embase, MEDLINE (via Ovid), Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and VIP Database). The date of the most recent search was 22 March 2017. Randomized controlled trials, controlled clinical trials, cohort studies, and before-after studies comparing the effect of PFM and other treatments on TMJ were included. The data were collected and extracted by three authors. The risk of bias in the RCTs was assessed in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. For the nonrandomized studies, the risk of bias was judged with Newcastle-Ottawa Scale. RESULTS: For the 261 articles identified, 13 studies with 522 participants were included for the final qualitative analysis. Three studies were graded as high value of evidence, while seven studies and the other three studies were graded as moderate value and low value respectively. According to the available evidence, PFM contributed to the significant increase of CondAx-SBL and the significant decrease of CondAx-ML. Thin-plate spline (TPS) analysis showed a horizontal compression in condyles. Condyles tended to move superiorly and posteriorly. Concerning the occurrence of temporomandibular disorders (TMD), PFM was not involved in aggravating TMJ symptoms and signs. CONCLUSIONS: Clinical evidence suggests that PFM might contribute to the morphologic adaptation of TMJs and displacement of condyles, and PFM may well be not a risk factor for the development of TMD.

Assessment of upper airway size after orthopedic treatment for maxillary protrusion or mandibular retrusion.

INTRODUCTION: The aim of this retrospective study was to find out whether different Class II treatments would affect the airway sizes of patients having maxillary protrusion or mandibular retrusion. METHODS: The study sample comprised 57 Class II patients whose upper airway sizes were not significantly different at the start of treatment and whose sagittal skeletal jaw relationships showed that they had maxillary protrusion or mandibular retrusion. Twenty-two of them were treated with cervical headgear, 16 with activator, and 19 were selected as a control. Lateral cephalograms at the start of treatment and the end of orthopedic treatment were assessed. The intragroup comparisons were performed by using the paired-samples t test, and intergroup comparisons of the skeletal features and upper airways were performed with 1-way analysis of variance, with the Tukey test as a second step, at P < 0.05. RESULTS: The ANB angle decreased significantly in the treatment groups. The middle airway space and the SNB angle were significantly increased after the activator therapy (P < 0.05). The SNB angle increased and SN-1 decreased in the mandibular retrusion group when compared with both maxillary protrusion and control groups. No statistically significant difference between the maxillary protrusion and the mandibular retrusion groups was found regarding the upper airway sizes after cervical headgear or activator treatments, respectively (P > 0.05). The only significant differences observed in airway variables were at the middle airway space of the activator and control groups with an increase of 1.6 ± 2.5 mm and a decrease of 1.5 ± 2.3 mm, respectively. CONCLUSIONS: Orthopedic treatment with either cervical headgear or activator did not result in different upper airway changes, but activator treatment resulted in increased middle airway space with regard to the Class II control group.

Effectiveness of early orthopaedic treatment with headgear: a systematic review and meta-analysis.

Background: Although the headgear appliance has been used extensively to correct anteroposterior discrepancies, its treatment effects have not yet been adequately assessed in an evidence-based manner. Objective: Aim of this systematic review was to assess the therapeutic and adverse effects of early headgear treatment from controlled clinical trials on human patients in an evidence-based manner. Search methods: An unrestricted electronic search of six databases from inception to December 2015. Selection criteria: Randomized and prospective non-randomized controlled trials assessing the effects of headgear treatment on human patients. Data collection and analysis: After duplicate study selection, data extraction, and risk of bias assessment according to the Cochrane guidelines, random-effects meta-analyses of mean differences (MDs) and relative risks (RRs), including their 95% confidence intervals (CIs) were performed, followed by subgroup and sensitivity analyses. Results: A total of 18 unique studies with a total of 930 (56% male/44% female) patients were included. Headgear treatment was associated with a posterior translation of the anterior maxilla border in the short term, as seen by the mean annualized change in the SNA angle (MD = -1.63°/year; 95% CI = -2.20 to -1.06°/year; high quality evidence) compared to untreated patients. This effect was independent of the rotation of the palatal plane and the inclination of the upper incisors, while a proportional relationship with the initial discrepancy in SNA was seen. The clinical significance of this improvement diminished in the long term, although only limited evidence existed. Additionally, early headgear treatment might decrease the risk of dental trauma during the following years (RR = 0.34; 95% CI = 0.14 to 0.80; moderate quality evidence). Low quality evidence on the effect of headgear on the rotation of the palatal plane, the nasolabial angle, the occlusal outcome, and signs of temporomandibular disorders precluded robust assessments, due to risk of bias, inconsistency, imprecision, and small-study effects. Conclusions: Based on existing trials, headgear is a viable treatment option to modify sagittal growth of the maxilla in the short term in Class II patients with maxillary prognathism. Registration: PROSPERO (CRD42015029837). Funding: None.

An Unusual Allergic Response to Orthodontic Treatment.

This paper describes a case of a 13-year-old patient with a systemic hypersensitivity reaction to orthodontic treatment. Her allergy was investigated resulting in a provisional diagnosis of pressure urticaria. The aetiology, diagnosis and clinical management of allergic reactions to dental procedures are discussed.

Periodontal Side Effect During Orthopedic Face Mask Therapy.

A 7-year-old patient exhibited gingival recession of tooth #41 and severe plaque accumulation after 3 months of face mask therapy. The recession improved only slightly after appropriate oral hygiene instructions and motivation. Decisive improvement began when the vertical chin pad extension was reduced to avoid pressure on the affected area.

Pressure-induced alopecia from orthodontic headgear.

UNLABELLED: Every treatment in the dental specialty has its own set of complications, Orthodontic therapy being no exception. Such a problem during the course of treatment puts the specialist in a dilemma as to whether to continue or stop the treatment. One such case in which during headgear therapy, a rare complication such as alopecia was encountered has been dealt with in this paper. This case report shows its effective management while still continuing treatment, thus leading to the desired result. It emphasizes on the importance of maintaining a balance between the benefts and risks of a treatment. CLINICAL RELEVANCE: The use of headgear can lead to the rare complication of alopecia and the clinician should be aware of it. OBJECTIVE: The reader should understand the psychological implications of alopecia and also to carry out the treatment after assessing the risk/beneft ratio.

Reverse Forsus vs. facemask/rapid palatal expansion appliances in growing subjects with mild class III malocclusions : A randomized controlled clinical study.

PURPOSE: To investigate the skeletal, dental, and soft tissue effects of reverse Forsus (RF; 3M Unitek, Monrovia, CA, USA) and facemask/rapid palatal expansion (FM/RPE) appliances in growing subjects with class III malocclusions. METHODS: The data of this prospective randomized controlled trial (RCT) were derived from pre- and posttreatment/observation lateral cephalograms of 45 subjects with mild class III malocclusions: group 1 (8 girls, 7 boys; mean age 10.54 years) received a FM/RPE appliance; group 2 (6 girls, 9 boys; mean age 10.49 years) received the RF appliance; and an untreated control group (7 girls, 8 boys; mean age 10.66 years) was matched to the treatment groups with regard to sagittal skeletal and dental classifications. Angular and linear measurements were evaluated using lateral cephalograms. Statistical analyses were performed by one-way analysis of variance, Kolmogorov-Smirnov test, Kruskal-Wallis, paired-samples t­test, and Wilcoxon test, whereby p < 0.05 was accepted to be statistically significant. RESULTS: The intermaxillary (ANB), interdental (overjet), and sagittal lip relations in the FM/RPE and RF groups showed significant improvements compared to the control group (p < 0.05). Although the anterior and inferior traction of the maxilla was greater in the FM/RPE group compared to the RF group (p < 0.05), both treatment groups showed similar clockwise rotation of the mandible compared to the control group. While significantly more proclination of maxillary incisors occurred in the RF group compared to the FM/RPE and control groups (p < 0.05), both treatments led to significantly retroclined mandibular incisors compared to the control group (p < 0.001). CONCLUSION: Both therapies led to intermaxillary and interdental improvements. The RF appliance had a limited effect on the maxilla and it mostly had dentoalveolar effects when compared to FM/RPE therapy.

Emergency orthodontic care.

Orthodontic appliances or parts of orthodontic appliances have caused problems from less severe like discomfort, ulcers and irritation of lips or cheeks to most severe problems like swallowing or aspiration of appliances or its parts. The type of appliances that have caused problems and their clinical management are discussed. Suggestions are made to try and avoid the problems that were encountered in the literature in patients undergoing orthodontic treatment.

Effects of 2 types of facemasks on condylar position.

INTRODUCTION: The aim of this study was to compare Delaire and Grummons protraction facemasks with a new articulator system (Amtech MG1, American Technologies, Brazil) that can record condylar positions. METHODS: Thirty-four patients treated with protraction facemask therapy were divided into 2 groups; 18 were treated with the Delaire facemask (DFM) and 16 with the Grummons facemask (GFM). The observation periods were 8.5 months for the DFM group and 10 months for the GFM group. Mandibular position indicator (MPI) recordings were taken with the new articulator system and evaluated before and after the protraction facemask therapies. RESULTS: MPI recordings in the sagittal plane showed forward and downward movement from centric relation to maximum intercuspal position for both condyles at the beginning of treatment for most patients. After treatment, the discrepancy between centric relation and maximum intercuspation was less in the DFM group than in the GFM group. However, more compressive movement of the condyles through the glenoid fossa was observed in the DFM group. CONCLUSIONS: Although the centric slide amount decreased more with the Delaire facemask compared with the Grummons facemask, patients treated with the Delaire facemask must be monitored for signs and symptoms of temporomandibular joint disorder.

Analysis of failure in the treatment of impacted maxillary canines.

INTRODUCTION: In this study, we aimed to evaluate the reasons for failure of orthodontic treatment for impacted maxillary canines and to recommend measures to overcome them. METHODS: Twenty-eight patients (ages, 17.4 +/- 4.3 years) with 37 maxillary impacted canines were referred after a failed attempt to resolve the impaction. Reasons for failure were analyzed, and corrective measures undertaken. The success rate of the revised treatments and the durations of both treatments were recorded. RESULTS: The mean duration of the failed treatments was 26.2 +/- 17.2 months. The failed treatments were mostly based on plane radiographs, intra-arch dental anchorage, and elastic traction directly to the labial archwire. The major reasons for failure were inadequate anchorage (48.6%), mistaken location and directional traction (40.5%), and ankylosis (32.4%). In several patients, there was more than 1 possible reason for failure. The success rate of the revised treatments was 71.4%, and the mean duration was 14.4 +/- 7.2 months. Repeat surgery was needed for 62.9% of the canines in which corrective treatment was started, mostly to redirect the ligature wires. The corrective measures included the use of 3-dimensional imaging and a change in the direction of traction. Anchorage was reinforced by dental and skeletal means. CONCLUSIONS: Inaccurate 3-dimensional diagnosis of location and orientation of impacted teeth and failure to appreciate anchorage demands were the major reasons for failure in the treatment of impacted canines.

Pharyngeal airway dimensions after chin cup treatment in Class III malocclusion subjects.

The objective of this study was to examine if chin cup therapy have any adverse effect on the sagittal pharyngeal dimensions in Class III malocclusion patients. Twenty patients (10 girls and 10 boys; mean age 10.31 +/- 1.15 years) with skeletal Class III malocclusion, and an untreated control group (8 girls and 10 boys, mean age 9.89 +/- 1.55 years) were evaluated. The chin cup appliance and an occlusal bite plate with 600 grams totally was used for 9.78 +/- 0.93 months. Linear, angular and area measurements were evaluated on the cephalometric radiographs taken before and after observation and treatment periods. Treatment changes showed significant increases in maxillary forward position, effective length of the maxilla and the mandible, and vertical facial height measurements. The mandible showed a clockwise rotation revealed by the decrease in SNB and the increase in mandibular plane angles. Significant increase in the nasopharyngeal area was found when the treatment and control groups were compared. The nasopharyngeal airway area was affected by chin cup treatment, without any adverse effect on the pharyngeal airway dimensions in the short term.

Cervicofacial emphysema secondary to facebow injury: a case report.

AIM: To report the clinical case of a child with facial and periorbital emphysema caused by an orthodontic device. CASE REPORT: An 11-year-old child presented to our clinic showing moderate swelling of the left facial area. Based on his dental history, physical findings, and instrument examinations, the diagnosis of cervicofacial emphysema was established, caused by disengagement of the facebow. One week later, all swelling and crepitus had disappeared without complications. Most patients who develop subcutaneous emphysema after a dental procedure have only moderate local swelling, which normally resolves spontaneously and without complications within a week. However the spread of large amounts of air into the deeper spaces may cause life-threatening sequelae. CONCLUSIONS: Orthodontists should be aware that the use of extraoral traction applied via a facebow can cause soft tissue injures and emphysema of the cervicofacial region. It is important to avoid misdiagnosis and to appropriately inform patient and parents about this condition.

Pressure alopecia from orthodontic headgear.

Pressure alopecia is a form of nonscarring hair loss that occurs because of chronic pressure. This article reports the appearance of an unusual area of pressure alopecia in a patient who wore headgear. Early diagnosis of this rare pathology is fundamental to obtaining total regression of the disease; although pressure alopecia is initially nonscarring, scarring can develop over time. Orthodontists should be aware that alopecia in predisposed patients can be caused by headgear.

Evaluation of temporomandibular disorders in Class III patients treated with mandibular cervical headgear and fixed appliances.

INTRODUCTION: Our aim in this study was to evaluate the prevalence of temporomandibular disorders (TMD) in Class III patients treated with mandibular cervical headgear (MCH) and fixed appliances. METHODS: The sample of 75 patients included 25 patients with no previous orthodontic treatment, 25 Class I patients who had undergone orthodontic treatment with fixed appliances and without extractions, and 25 patients with dentoskeletal Class III disharmonies treated with MCH and fixed appliances. The Helkimo index was used to test the prevalence of TMD symptoms in the 3 groups. The prevalence rates of the Helkimo index in the 3 groups were compared with the z score on proportions. RESULTS: No statistically significant differences in the prevalence rates of the Helkimo index scores in the 3 groups were found (P = .367). Most subjects in the 3 groups had an Helkimo index of zero (66.7%). CONCLUSIONS: Subjects with Class III malocclusions treated with MCH and fixed appliances do not have greater prevalence of TMD symptoms than do Class I subjects treated with fixed appliances or untreated subjects.

Soft tissue profile after distal molar movement with a pendulum K-loop appliance versus cervical headgear.

OBJECTIVE: To evaluate the soft tissue changes associated with the pendulum appliance that was supported with a K-loop buccally and to compare these treatment changes with a cervical headgear group. MATERIALS AND METHODS: The records of 30 patients having skeletal Class I, dental Class II malocclusions were divided to two groups. Group 1 consisted of 7 girls, 8 boys (mean age, 15.0 +/- 3.4 years), and Group 2 consisted of 10 girls, 5 boys (mean age 14.2 +/- 2.9 years). The first group was treated with a pendulum appliance that was supported with a K-loop buccally, and the second group was treated with cervical headgear. Lateral cephalograms were taken at the beginning of treatment and at the end of distal molar movement. Treatment changes within the groups were analyzed using the paired t-test, and between group changes were analyzed with the independent t-test. RESULTS: The results showed that the pendulum/K-loop appliance had no significant effect on skeletal and dental variables and soft tissue A point, upper lip thickness, and sagittal upper lip position relative to the E plane. A significant difference for the change in Vp-Ls distance was found in patients in the pendulum/K-loop group (P < .05). Patients in the cervical headgear group showed significant retrusion in skeletal, dental, and soft tissue measurements (P < .05). CONCLUSIONS: The pendulum/K-loop appliance produces distal molar movement without causing any significant changes in the sagittal or vertical positions of either the jaw or the soft tissue profile.

Skin irritation from a facial mask in Class III malocclusion: evaluation of individual silicone chin cups in a group of 100 children.

BACKGROUND: Reverse headgear (a facial mask) is one of the most frequently used interceptive orthodontic devices in patients with Class III malocclusion. It is a simple device but may present some drawbacks related to pressure on the skin generated by the forehead and chin supports linked to the maxillary intraoral appliance by elastics. This can cause injury to the chin and lips. METHODS: Patients between 7 and 8 years of age were selected from the Unit of Pediatric Dentistry. Orthopedic therapy with a rapid palatal expander and reverse headgear was prescribed for all subjects. The patients were divided into two groups: those who used a facial mask without a silicone chin cup and those who used a facial mask with a silicone chin cup. RESULTS: Two-hundred subjects including 90 male patients and 110 female patients were enrolled. The groups that used a facial mask with and without a silicone chin cup included 100 patients each. The percentage of subjects without irritation was significantly greater in the group with a silicone chin cup than in the group without a silicone chin cup. CONCLUSIONS: The authors propose a simple and effective solution to prevent skin irritation on the chin caused by a facial mask. A chin mask is a custom solution that can prevent injury to the chin during treatment when coupled with facial mask therapy.

Quantitative comparison of incisal tooth wear in patients receiving one-phase or two-phase treatment for skeletal Class III malocclusion with anterior crossbite.

OBJECTIVES: The present study aimed to compare the amount of incisal tooth wear in the maxillary central incisors of patients with skeletal Class III malocclusion and anterior crossbite receiving one-phase or two-phase treatment. The hypothesis was that tooth wear would differ according to treatment modalities. MATERIALS AND METHODS: Maxillary dental casts obtained before (T1) and after (T2) orthodontic treatment were divided into three groups. Group I consisted of casts from 21 patients (7 males, 14 females; mean age 9.8 years) who received two-phase treatment (maxillary protraction followed by fixed appliance therapy). Group II comprised casts from 37 patients who underwent orthodontic camouflage treatment for crossbite, subdivided according to age. Group IIa consisted of casts from 15 adolescents (8 males, 7 females; mean age 13.5 years), and group IIb consisted of casts from 22 adults (13 males, 9 females; mean age 24.5 years). Maxillary dental casts obtained at T1 and T2 were scanned. For each pair of digital images, T2 was superimposed on T1 using the best-fit method. Tooth wear was quantified and compared among groups. RESULTS: Significantly less tooth wear was observed in group I compared to groups IIa and IIb, but no difference was found between groups IIa and IIb. Spearman correlation analysis revealed no significant correlation between tooth wear and age, treatment duration, or craniofacial morphology. CONCLUSIONS: Despite the long duration of early treatment, it caused less wear of the maxillary central incisors than did orthodontic camouflage treatment.

Effects of facemask therapy on the mandibular retromolar space. A follow-up study.

OBJECTIVES: To evaluate the mandibular retromolar space after facemask therapy and a follow-up period.  Methods: This retrospective study was conducted between May and September in 2014. The sample consisted of pre-treatment (T1), post-treatment (T2), and follow-up(T3) panoramic radiographs of 19 skeletal and dental Class III patients (7 female, 12 male; mean age: 10.5 years) treated with facemask and a removable intraoral upper appliance in the Faculty of Dentistry Gazi University, Ankara, Turkey. Each patient's lower arches were evaluated as right and left segments. As third molars were congenitally absent in 3 segments, a total of 35 segments were evaluated. The average treatment time was one year. The average follow-up period was 2.4 years. The positions, angulations, dental maturations of lower third molars, and mandibular retromolar spaces (DJ) were assessed. Friedman's 2-way Analysis of Variance, multiple-comparison, Pearson's correlation, and Chi-square tests were used for statistical evaluation. A p less than 0.05 was considered as significant. RESULTS: The angulation of the first molar (ϒ) increased significantly only in the follow-up period (T3). Mandibular retromolar spaces were increased significantly during all periods. The most commonly determined position of the third molar, by Winter's classification, was vertical angulation in all periods. Moderate and significant correlations were found between third molar angulation(ß) and DJ at T2 and T3. Significant correlations were also found between DJ and Demirjian classification stages during all periods. CONCLUSION: Facemask therapy did not have an adverse effect on the mandibular retromolar space during treatment and follow up periods.

Traumatic ulcers and pain during orthodontic treatment.

In the present investigation the frequency of oral ulcers and pain in 161 orthodontic patients was recorded. Of all patients, 95% had experienced pain, but 84.5% said that the pain lasted a few days only. About 11% maintained that the treatment was constantly painful. Significantly more patients coming from private clinics complained of pain than those attending treatment at the Department of Orthodontics. About 50% said that activating or changing archwire was most annoying, whereas 28.7% said ulceration and 21% said headgear was the most annoying part of the treatment. According to 75% of the patients, sleeping habits were not influenced. Only eight patients reported truancy, and seven of these had done this only once. Of all patients, 6.2% had requested interim visits. Small wounds caused by the fixed appliance were reported by 75.8% of the patients, and 2.5% had suffered badly from ulceration caused by the fixed appliances. More girls than boys reported ulceration. There was a significant sex difference as regards recurrent aphthous ulceration (RAU). Increase in the frequency of RAU was reported by 23.1% of the girls and 9.6% of the boys while they had fixed appliances.