Effect of post-printing curing time on cytotoxicity of direct printed aligners: A pilot study.

INTRODUCTION: The aim of this in vitro study was to examine the potential impact of different curing times of 3D-printed orthodontic aligners on their cytotoxicity. METHOD: Some 60 samples of aligner material were directly 3D printed using Tera Harz TC-85 DAC resin and randomly allocated to three different curing time groups (14, 24 and 50 min). Zendura FLX samples were used as control. The samples were incubated in saliva for 14 days, and then the supernatant was collected. Human gingival fibroblasts (HGF-1)-CRL2014 were used to evaluate potential cytotoxicity. Furthermore, HGF-1 cells were plated on the samples as well as on a glass control sample. After 72 h of growth, their viability was tested. RESULTS: Compared with the glass, only the 50-min curing time markedly reduced fibroblast cell growth. Additionally, a negative linear trend was observed between curing time and fibroblast growth. In comparison with the aligner control group, all samples, including the aligner control samples, exhibited a significant reduction in the viability of human fibroblasts when exposed to saliva. CONCLUSIONS: 3D directly printed aligners showed a cytotoxic effect similar to that of thermoformed conventional aligners in terms of fibroblasts growth. A linear trend was found between curing time and cells growth, indicating that directly printed aligners could exhibit higher cytotoxicity if exposed to a longer curing time. This dependence on curing time underscores the importance of following a strict manufacturing process.

Midpalatal miniscrew insertion: The accuracy of digital planning and surgical placement.

INTRODUCTION: The objective of this study was to investigate the accuracy of palatal miniscrew insertion, evaluating the effect of guide fabrication and surgical placement. METHODS: Guided insertion of bilateral paramedian palatal miniscrews was undertaken using Appliance Designer software (3Shape, Copenhagen, Denmark). A resin surgical guide (P Pro Surgical Guide; Straumann AG, Basel, Switzerland) was used. Superimposition of the miniscrew position relative to the digital design was undertaken using bespoke software (Inspect 3D module, OnyxCeph; Image Instruments GmbH, Chemnitz, Germany) to assess surgical inaccuracy. Miniscrew position relative to the surgical guide was also assessed to isolate the effect of planning inaccuracies. Both horizontal and vertical discrepancies were evaluated at both implant locations. RESULTS: Twenty-seven patients having bilateral palatal insertions were examined. Mean discrepancies were <0.5 mm, both in the horizontal and vertical planes. The mean overall horizontal and vertical discrepancy between the digital design and final miniscrew position on the left side was 0.32 ± 0.15 mm and 0.34 ± 0.17 mm, respectively. The maximum horizontal discrepancy observed was 0.72 mm. No significant differences were observed in relation to the accuracy of mini-implant positioning on the basis of sidedness, either for horizontal (P = 0.29) or vertical (P = 0.86) discrepancy. CONCLUSIONS: High levels of accuracy associated with guided insertion of paramedian palatal implants were recorded with mean discrepancies of less than 0.5 mm both in the horizontal and vertical planes. No difference in accuracy was noted between the left and right sides. Very minor levels of inaccuracy associated both with surgical techniques and surgical guide fabrication were recorded.

Performance of dental students, orthodontic residents, and orthodontists for classification of midpalatal suture maturation stages on cone-beam computed tomography scans - a preliminary study.

BACKGROUND: Assessment of midpalatal suture maturation on cone-beam computed tomography (CBCT) scans is performed by visual inspection and is therefore subjective. The extent to which the assessment of midpalatal suture maturation is affected by rater experience has not been adequately explored in the existing literature, thus limiting the availability of evidence-based findings. This study compared the outcomes of classification by dental students, orthodontic residents, and orthodontists. METHODS: Three different groups of students, orthodontic residents, and orthodontists evaluated 10 randomly chosen CBCT scans regarding midpalatal suture maturation from a pool of 179 patients (98 female and 81 male patients) aged 8 - 40 years which were previously classified by evaluating CBCT scans. The pool was set as benchmark utilizing midpalatal suture maturation classification by one examiner (OsiriX Lite version 11.0; Pixmeo SARL, Bernex, Switzerland). For assessment of intra-rater reliability of the examiners of each group the randomly chosen subjects were reclassified for midpalatal suture maturation after a wash-out period of two weeks by using the same software. Statistical analysis was performed to evaluate intra- and interrater reliability of the three groups with differing experience level. RESULTS: Groupwise intra-rater reliability assessment between the classification and reclassification was weak for examiners with a low level of experience (k = 0.59). Orthodontists had highest degree of agreement with regard to benchmark classification with an inter-rater reliability to be considered as moderate (k = 0.68). CONCLUSIONS: Assessment of midpalatal suture maturation on CBCT scans appears to be a subjective process and is considerably related to the experience level of the examiner. A high level of clinical experience seems to be favorable but does not necessarily ensure accurate results.

Three-dimensional comparison of tooth-borne and tooth-bone-borne RME appliances: a randomized controlled trial with 5-year follow-up.

OBJECTIVES: To compare the long-term skeletal effects of tooth-borne (TB) and tooth-bone-borne (TBB) rapid maxillary expansion in growing children, using 3D imaging. MATERIALS AND METHODS: In total, 52 consecutive patients who met the eligibility criteria were recruited and allocated to either the TB group, mean age 9.3 years (SD 1.3), or the TBB group, mean age 9.5 years (SD 1.2). Cone-beam computed tomography records and plaster models were taken before (T0), directly after (T1), 1 year after (T2), and 5 years after expansion (T3). RANDOMIZATION: Participants were randomly allocated in blocks of different sizes, using the concealed allocation principle in a 1:1 ratio. The randomization list was also stratified by sex to ensure homogeneity between groups. BLINDING: Due to clinical limitations, only the outcome assessors were blinded to the groups to which the patients were allocated. RESULTS: At T1, the midpalatal suture at its anterior part showed a statistically significant difference between the groups with a mean of 0.6 mm (CI 0.2-1.1) more expansion in the TBB group (P < 0.01). This difference was also more evident in boys at T1 with a mean of 0.8 mm (CI 0.2-1.4) (P < 0.01). These differences, however, blotted out at T2 and T3. The nasal width also showed similar differences between the groups, with a significantly larger expansion in the TBB group by a mean of 0.7 mm (CI 0.1-1.4) (P = 0.03). This group difference in favour of the TBB group was maintained at T2 (1.6 mm) and T3 (2.1 mm) (P < 0.01 T2 and T3, respectively). CONCLUSIONS: Skeletal expansion in the midpalatal suture was significantly higher in the TBB group; however, the magnitude of this expansion was around 0.6 mm more and may not be clinically significant. Skeletal expansion at the level of the nasal cavity was significantly higher in the TBB group. There were no differences between boys and girls with regard to skeletal expansion. TRIAL REGISTRATION: This trial was not registered on any external sites.

Skeletal and dentoalveolar effects using tooth-borne and tooth-bone-borne RME appliances: a randomized controlled trial with 1-year follow-up.

OBJECTIVES: To evaluate and compare the skeletal and dentoalveolar effects of tooth-borne (TB) and tooth-bone-borne (TBB) rapid maxillary expansion (RME). MATERIALS AND METHODS: Fifty-two consecutive patients who met the eligibility criteria were recruited and allocated to either the TB group, mean age 9.3 years [standard deviation (SD) 1.3], or the TBB group, mean age 9.5 years (SD 1.2). Cone-beam computed tomography (CBCT) records and plaster models were taken before (T0), directly after (T1), and 1 year after expansion (T2). Dentoalveolar and skeletal measurements were made on the CBCT images. The dental expansion was also measured on the plaster models. RANDOMIZATION: Participants were randomly allocated in blocks of different sizes using the concealed allocation principle in a 1:1 ratio. The randomization list was also stratified by sex to ensure homogeneity between groups. BLINDING: Due to clinical limitations, only the outcomes assessors were blinded to the groups to which the patients were allocated. RESULTS: Skeletal expansion in the midpalatal suture and at the level of the nasal cavity was significantly higher in the TBB group. However, the magnitude of the expansion in the midpalatal suture was around 1 mm [95 per cent confidence interval (CI) 0.5-1.7, P = 0.001] more and perhaps not clinically significant. The magnitude of the expansion at the level of the nasal cavity was almost two times higher in the TBB group (95 per cent CI 0.7-2.6, P = 0.001). The dental expansion, alveolar bending, tipping of the molars, and stability 1 year post-expansion did not show any statistically significant differences between the groups. The actual direct cost of the treatment for the TBB group was approximately €300 higher than TB group. LIMITATIONS: Double blinding was not possible due to the clinical limitations. CONCLUSIONS: In young preadolescents with constricted maxilla and no signs of upper airway obstruction, it seems that conventional TB RME achieves the same clinical results with good stability 1 year post-expansion at lower cost. TRIAL REGISTRATION: The trial was not registered.

Effects on nasal airflow and resistance using two different RME appliances: a randomized controlled trial.

Objectives: To evaluate and compare the effects of tooth-borne (TB) and tooth-bone-borne (TBB) rapid maxillary expansion (RME) on nasal airflow and resistance. Material and methods: Fifty-four consecutive patients who met the eligibility criteria were recruited from September 2010 to December 2015. Of these 54 subjects, 40 agreed to participate in the part of the study involving evaluation of nasal flow and resistance. The 40 subjects were allocated to either the TB group, mean age 9.7 years (SD 1.5), or the TBB group, mean age 10.2 years (SD 1.4). All subjects performed rhinomanometric registration at baseline (T0), but only 30 attended the post-expansion registration (T1), of whom 16 had been randomized to the TB group and 14 to the TBB group. The study outcomes, nasal airflow and nasal airway resistance, were evaluated with linear regression adjusted for baseline variable of the outcome to compare the study groups with complete cases strategy as well as after multiple imputation (MI). Randomization: Participants were randomly allocated in blocks of different sizes, using the concealed allocation principle in a 1:1 ratio. The randomization list was computer generated to ensure homogeneity between groups. Blinding: Blinding was done only for outcome assessor due to clinical limitations. The care providers at the ENT unit who conducted all the rhinomanometry examinations were blinded to which group the patients were allocated to. Results: Complete case analysis showed significantly higher post-expansion nasal airflow values for the TBB group compared with the TB group, mean difference 51.0 cm3/s (P = 0.018). The evaluation after MI showed a similar significant mean difference, 52.7 cm3/s (P = 0.020) in favour of the TBB group when taking into account the missing values from the T1 examination. Even reduction in nasal airway resistance showed similar pattern in favour of the TBB group. Limitations: Our results represent the short-term effects. A longer follow-up period would have been preferable. Conclusions: The TBB RME induced significantly higher nasal airway flow and lower nasal resistance values than TB RME. It might be wiser to use TBB RME in cases with constricted maxilla and upper airway obstruction. Registration: This trial was not registered in any external sites. Protocol: The protocol was not published before trial commencement.

Increased BMI in children-an indicator for less compliance during orthodontic treatment with removable appliances.

Aim: To assess whether or not childhood overweight is associated with lower levels of compliance during orthodontic therapy with removable appliances. Materials and methods: Starting in 2011, all upper expansion plates and Sander II appliances were equipped with a Theramon® microsensor chip to assess appliance wear time objectively. According to their pre-treatment, BMI normal weight patients were matched to consecutively treated overweight or obese patients by gender, age, and appliance type. Cooperation was assessed with microelectronic wear time documentation over a period of at least 6 months. Results: A total of 50 patients (25 overweight, 25 normal weight) with upper expansion plates and 64 patients (32 overweight, 32 normal weight) with Sander II appliances were analysed. Spearman Rho coefficients showed an indirect association between BMI and appliance wear time, indicating that the higher the BMI, the less the patients wore their appliances (P < 0.05). Furthermore, both normal- and overweight children wore upper expansion plates significantly more than Sander II appliances (P < 0.05). Although no gender-specific difference was found (P = 0.723), an age-related correlation could be verified, indicating a decrease in wear time with increasing age (P < 0.05). Conclusions: An increased BMI appears to be a risk factor for less appliance wear during orthodontic treatment with removable appliances. Additional factors which influenced cooperation during treatment with removable appliances were patient age and appliance type.

Anatomic landmarks and availability of bone for placement of orthodontic mini-implants for normal and short maxillary body lengths.

INTRODUCTION: Increasing numbers of orthodontic mini-implants are placed in the anterior maxilla. To our knowledge, bone levels and root proximity of patients with cephalometrically short maxillae have not been investigated before. The first, second, and third rugae were used as clinical reference lines, and the aim of this study was to measure bone availability in that area by comparing patients with short and normal maxillary body lengths. METHODS: The sample consisted of 21 patients in each group: short maxillary body length and normal maxillary body length. The patients' study models were bisected, and the outline of the palatal contour was marked on the surface. The models were scanned, and the palatal contours were superimposed on the palatal structures of their respective initial cephalometric headfilms, and the vertical and oblique bone levels of the sagittal plane were compared using the Student t test. The level of significance was set at P <0.05. RESULTS: Compared with maxillae of normal maxillary body length, less bone was available in maxillae of short maxillary body length. However, the differences did not reach clinical or statistical significance (P >0.05) at the third rugae. CONCLUSIONS: Almost equivalent average bone depth at the third rugae in patients with normal and short maxillary body lengths suggests that this site can be used for 8-mm long obliquely inserted orthodontic mini-implants.

The nasopalatine canal, a limiting factor for temporary anchorage devices: a cone beam computed tomography data study.

OBJECTIVES: There is only little knowledge on topographical predispositions of the nasopalatine canal as a limiting factor for insertion of mid-palatal temporary anchorage devices (TAD). The purpose of the study was to assess the course of the nasopalatine canal, the adjacent vertical bone quantity, and whether it might differ among vertical facial types, using pre-existing cone beam computed tomography (CBCT) scans. MATERIAL AND METHODS: Out of a consecutive sample collected from April 2008 to August 2012, only patient data depicting both upper and lower jaw completely were evaluated retrospectively. The linear measurements were taken on the respective midsagittal view perpendicular to the palate at the level of 1st molar/2nd premolar (5/6), 2nd premolar/1st premolar (4/5), and 1st premolar/canine (3/4). Screen-prints were used to measure the inclination of the nasopalatine canal in relation to the maxillary jaw base. Maxillary and mandibular divergence was assessed on rendered lateral cephalograms. RESULTS: Out of 3869 pre-existing consecutive CBCT scans, data from 398 patients met the inclusion criteria and could be extracted. The mean vertical bone was 4.09 mm at the 5/6 level, 5.22 mm at the 4/5 level, and 3.14 mm at the 3/4 level, respectively. A statistically significant negative correlation exists between jaw divergence and the canal angulation with regard to the maxillary base. A statistically significant negative correlation exists between the canal angulation and vertical bone measurements at the 4/5 and 3/4 levels. CONCLUSIONS: Vertical bone volume is sufficient at 4/5 level for TAD placement, and bares only a small risk for neuro-sensory impairment. Therefore, only in rare cases a CBCT is justified for palatal implant placement. The course of the nasopalatine canal is negatively correlated with the vertical skeletal facial pattern pointing to the fact that in hypodivergent patients a TAD might be placed in a more distal or paramedian region.

Rapid-maxillary-expansion induced rhinological effects: a retrospective multicenter study.

Conventional dental-borne rapid maxillary expansion (RME) leads to a widening of the airways, followed by improved nasal breathing. Although combined skeletal-dental appliances are nowadays being inserted increasingly often and provide a force at the center of resistance in the nasomaxillary complex, no study exists so far that shows whether this treatment may improve the expansionary effect on the airways. In this study, low-dose computed tomography (CT) images from 31 patients (average age 14.63 ± 0.38 years) were examined retrospectively. Both records (T0 = before expansion and T1 = immediately after maximum expansion) were taken in a time interval of 25 days to avoid growth influence. Five patients were treated with Hyrax RME, 6 patients with Hybrid RME, and 20 patients with acrylic cap RME. The total airway volume increased highly significantly (mean +7272.6 mm(3); P < 0.001, power = 0.998), representing an average airway expansion of +11.54 % (2.35 %/mm activation). While the nasopharynx and oropharynx showed highly significant expansion (P < 0.000, power = 0.999), the airway at the laryngopharynx did not change significantly (P > 0.779, power = 0.05). Although the patients were significantly older in the Hybrid RME group (P = 0.006), the positive rhinological effects were comparable within all groups of different appliances (P > 0.316). Hybrid RME may, therefore, be an advisable procedure in patients with nasomaxillary impairment and pronounced patient's age.

Stability of paramedian inserted palatal mini-implants at the initial healing period: a controlled clinical study.

OBJECTIVES: To assess the stability development of paramedian in comparison with midpalatal inserted mini-implants. MATERIAL AND METHODS: The test group consisted of 21 consecutively treated patients (13.7 ± 4.6 years). In each patient, a mini-implant was inserted paramedian in the anterior palate. Measurement of the insertion depth (ID), the maximum insertion torque (IT), and resonance frequency analysis (RFA) was performed at T0. RFA was repeated after 2 weeks (T1), 4 weeks (T2), and 6 weeks (T3). Correlations between measuring methods were calculated. RFA values at different times were tested for statistical differences. Data were compared with a group of patients who received median mini-implants of the same size. RESULTS: Initial stability was 14.06 ± 4.35 Ncm (IT) and 26.60 ± 5.28 ISQ (RFA) with an ID of 7.02 ± 1.04 mm. RFA and IT (r = 0.49, P = 0.023) showed a moderate significant correlation. Stability remained relatively constant, showing no significant differences between measurement times. Overall, RFA values decreased non-significantly by 2.25 ± 6.85 ISQ to a level of 24.35 ± 5.39 after 6 weeks. Comparing development of stability over time, it was found that significant differences were present at T0 and T1 (T0: -9.54 ISQ, P < 0.0001; T1: -3.69, P = 0.041). CONCLUSIONS: Paramedian inserted mini-implants provided sufficient stability. Showing a lower primary stability, RFA values did not differ from the control group from week four on, as no significant decrease in stability occurred at the initial healing period.

Quantifying patient adherence during active orthodontic treatment with removable appliances using microelectronic wear-time documentation.

OBJECTIVES: The aim of this study was to quantify the wear times of removable appliances during active orthodontic treatment. MATERIALS AND METHODS: The wear times of 141 orthodontic patients treated with active removable appliances in different locations were documented over a period of 3 months using an incorporated microsensor. Gender, age, treatment location, health insurance status, and type of device were evaluated with respect to wear time. Significant associations between wear times and patient factors were calculated using non-parametric tests. RESULTS: The median daily wear time was 9.7 hours/day for the entire cohort, far less than the 15 hours/day prescribed. Younger patients wore their appliances for longer than older patients (7-9 years 12.1 hours/day, 10-12 years 9.8 hours/day, and 13-15 years 8.5 hours/day; P < 0.0001). The median wear time for females (10.6 hours/day) was 1.4 hours/day longer than males (9.3 hours/day; P = 0.017). Patients treated at different locations wore their devices with a difference of up to 5.0 hours/day. Privately insured patients had significantly longer median wear times than statutorily insured patients. No significant difference in wear time was noted according to device type. CONCLUSIONS: The daily wear time of removable appliances during the active phase of orthodontic therapy can be routinely quantified using integrated microelectronic sensors. The relationship between orthodontist and patient seems to play a key role in patient adherence. Wear-time documentation provides the basis for more individualized wear-time recommendations for patients with removable appliances. This could result in a more efficient, shorter, and less painful orthodontic therapy.

Anchorage loss due to Herbst mechanics-preventable through miniscrews?

AIM: To assess if mandibular incisor proclination and protrusion during treatment with the Herbst/multibracket appliance can be prevented through simple screws (MIs) anchorage. MATERIAL AND METHODS: After a statistical power analysis, 12 Herbst patients with MIs (100% MIs survival) ligated to the Herbst/multibracket appliance to reinforce anchorage were investigated. A control group matched for gender and skeletal maturity treated without MIs anchorage was selected. Pre- and posttreatment cephalograms were analysed for overjet reduction, mandibular incisor proclination (IL/ML), protrusion (Ii-MLp) and intrusion (Ii-ML), as well as occlusal plane inclination (OP/ML) by a single-blinded examiner. RESULTS: No statistically significant differences between the two groups were found concerning overjet reduction, incisor protrusion- and intrusion or occlusal plane tilt. Although the MIs group generally showed less lower incisor proclination (4.8°) than the group without skeletal anchorage (6.5°), a large interindividual variation was observed. CONCLUSION: Interradicular MIs anchorage cannot prevent anchorage loss during Herbst treatment. For the individual patient, the amount of incisor proclination and protrusion remains unpredictable.

The most distal palatal ruga for placement of orthodontic mini-implants.

OBJECTIVE: To evaluate the stability and bone availability of the most distal (third) palatal ruga, as an anatomical region for safe insertion of orthodontic mini-implants (OMIs) in the anterior palate. STUDY DESIGN: Orthodontic records of 35 patients were analysed. Initial (T1) and final (T2) study models were bisected and the outline of the palatal contour was marked on the surface. Models were scanned and the palatal contours were superimposed on the palatal structures on the respective initial and final cephalometric images. Cephalometric measurements were used to assess vertical (3rdRug-PP, 2ndRug-PP, and 1stRug-PP), and oblique bone levels (3rdRug-U1, 2ndRug-U1, 1stRug-U1, and 3rdRug-U1(o)). Paired Student's t-test was used to compare measurements between T1 and T2. RESULTS: The position of the third palatal ruga remained stable during orthodontic treatment (Δ2ndRug-3rdRug P = 0.1mm; P = 0.61 and Δ1stRug-3rdRug P = 0.2mm; P = 0.39). Bone availability also remained adequate (3rdRug-U1T2 (o) = 9.9mm). CONCLUSION: The third palatal ruga is a reliable clinical landmark to evaluate bone availability for the placement of OMIs in the anterior palate.

Three dimensional anatomical exploration of the anterior hard palate at the level of the third ruga for the placement of mini-implants--a cone-beam CT study.

AIM: The aim of this retrospective investigation was to measure vertical bone thickness on the hard palate, determine areas with adequate bone for the insertion of orthodontic mini-implants (MIs), and provide clinical guidelines for identification of those areas. MATERIALS AND METHODS: Pre-treatment records of 1007 patients were reviewed by a single examiner. A total of 125 records fulfilled the inclusion criteria and were further investigated. Bone measurements were performed on cone-beam computed tomography scans, at a 90° angle to the bone surface, on 28 predetermined and standardized points on the hard palate. Bone thickness at various areas was associated to clinically identifiable areas on the hard palate by means of pre-treatment plaster models. RESULTS: Bone thickness ranged between 1.51 and 13.86 mm (total thickness) and 0.33 and 1.65 mm (cortical bone thickness), respectively. Bone thickness was highest in the anterior palate and decreased significantly towards more posterior areas. Plaster model analysis revealed that bone thickness was highest at the level of the third palatal ruga. CONCLUSIONS: The areas on the anterior palate with adequate bone thickness for successful insertion of orthodontic MI correspond to the region of the third palatal ruga. These results provide stable and clinically identifiable landmarks for the insertion of palatal MIs.