A heuristic model for cephalometric diagnosis of sagittal dysplasia.

OBJECTIVE: To identify the best-suited cephalometric parameter for assessing the sagittal skeletal discrepancy in the Indian population. DESIGN: An in vitro, observational, single-blinded, retrospective study. SETTING: Department of Orthodontics and Dentofacial Orthopaedics. METHODS: A total of 94 lateral cephalograms were used in this study. The study involved one key person and two examiners. The key person collected the radiographs, coded, analysed and classified them into three groups (skeletal classes I, II and III). Subsequently, the coded radiographs were independently analysed by the two examiners. They classified the cases by matching a minimum of 6 out of 11 parameters. On completion of diagnosis by the examiners, the samples were decoded and matched with the original diagnosis given by the key person. The samples in which identification of a particular cephalometric parameter matched the original evaluation as given by the key person was regarded as correctly diagnosed. The number of correctly assessed cases was used to judge the diagnostic performance of all the parameters in all the cases. Cross-validation of the method was performed, and a diagnostic algorithm was developed for diagnosis. RESULTS: ß angle and Pi angle showed a positive predictive value of 1 in both skeletal class I and II cases. ANB angle, W angle and HBN angle showed a positive predictive value of 1 in skeletal class III cases. CONCLUSION: No single cephalometric parameter can independently be used to diagnose sagittal skeletal discrepancy in all cases. However, a conclusive diagnosis on the type of sagittal skeletal malocclusion can be made by using a simple and easy to use diagnostic algorithmic process having a combination of cephalometric parameters.

ADAMTSL1 and mandibular prognathism.

Mandibular prognathism is characterized by a prognathic or prominent mandible. The objective of this study was to find the gene responsible for mandibular prognathism. Whole exome sequencing analysis of a Thai family (family 1) identified the ADAMTSL1 c.176C>A variant as the potential defect. We cross-checked our exome data of 215 people for rare variants in ADAMTSL1 and found that the c.670C>G variant was associated with mandibular prognathism in families 2 and 4. Mutation analysis of ADAMTSL1 in 79 unrelated patients revealed the c.670C>G variant was also found in family 3. We hypothesize that mutations in ADAMTSL1 cause failure to cleave aggrecan in the condylar cartilage, and that leads to overgrowth of the mandible. Adamtsl1 is strongly expressed in the condensed mesenchymal cells of the mouse condyle, but not at the cartilage of the long bones. This explains why the patients with ADAMTSL1 mutations had abnormal mandibles but normal long bones. This is the first report that mutations in ADAMTSL1 are responsible for the pathogenesis of mandibular prognathism.

Therapeutic Protocol for Orthosurgical Management of Class III Malocclusion in Patients With Cleidocranial Dysostosis.

Cleidocranial dysostosis (CCD) is a congenital skeletal disorder with significant manifestations in facial and dental development. Patients are affected with CCD present maxillary deficiency, late dental eruption, and supernumerary teeth. Early and multidisciplinary approach is necessary to treat CCD patients, especially to manage dental eruption and Class III malocclusion with maxillary deficiency. Several orthodontic and surgical interventions are performed to enable traction and extraction of teeth. Yet the maxillary deficiency may be protracted followed by orthodontic dental compensation. On the other hand, it is important to note that CCD patients' treatment is closely related to the severity of transversal and sagittal deformities, as well as the discrepancies in the lower third of the face. In this context, patients with facial impairment highly affected by CCD may need ortho-surgical decompensation to reach more aesthetic outcomes. The present study reports a case of a 14-year-old young patient affected by CCD. Clinically, the patient presented Class III malocclusion, maxillary deficiency, short lower facial third, posterior crossbite, and anterior open bite leading to facial disharmony. The patient underwent treatment in 2 stages: the interceptive approach aimed to transversally expand the maxilla and promote its protraction; and the corrective phase combined with the orthognathic surgery treated the patients' main complains; the anterior open bite, unerupted teeth, and chin prominence. The treatment approach applied in the clinical report allowed the correction of the malocclusion and facial profile satisfying completely the patient's expectations.

Extreme maxillomandibular discrepancy in unilateral cleft lip and palate: Longitudinal follow-up in a patient with mandibular prognathism.

Growth deficiency of the maxilla is a frequent finding in patients with complete unilateral cleft lip and palate. When the sagittal discrepancy is severe, orthodontic treatment combined with orthognathic surgery is required. This article reports the treatment of a girl born with unilateral cleft lip and palate who had lip and palate repair at 3 and 12 months of age, respectively. At 3 years of age, she already showed a severe anteroposterior maxillary deficiency with an anterior crossbite in the deciduous dentition. A Class III skeletal pattern progressively increased during the mixed dentition period. Mandibular prognathism coupled with an extremely hyperdivergent growth pattern was observed. An alveolar bone graft was performed at 10 years of age. At 16 years of age, the ANB angle was -13.7° with a negative overjet of -9.8 mm. Comprehensive orthodontic treatment was conducted with extraction of the mandibular first premolars and maxillary lateral incisors due to dental crowding. Orthognathic surgery was performed at 18.9 years of age involving maxillary advancement of 7.4 mm and mandibular setback of 6.6 mm. Facial and occlusal changes were dramatic. Final nose repair was conducted at 19.7 years of age. At 22 years of age and 3 years after debonding, stability of the occlusal and skeletal results was observed, clearly demonstrating that the objectives established for the rehabilitation have been achieved.

Genetic Factors Involved in Mandibular Prognathism.

Mandibular prognathism is defined as an abnormal forward projection of the mandible beyond the standard relation to the cranial base and it is usually categorized as both a skeletal Class III pattern and Angle Class III malocclusion. The etiology of mandibular prognathism is still uncertain, with various genetic, epigenetic, and environmental factors possibly involved. However, many reports on its coexistence in both twins and segregation in families suggest the importance of genetic influences. A multifactorial and polygenic background with a threshold for expression or an autosomal dominant mode with incomplete penetrance and variable expressivity are the most probable inheritance patterns. Linkage analyses have, thus far, shown the statistical significance of such loci as 1p22.1, 1p22.3, 1p32.2, 1p36, 3q26.2, 4p16.1, 6q25, 11q22, 12pter-p12.3, 12q13.13, 12q23, 12q24.11, 14q24.3 to 31.2, and 19p13.2. The following appear among candidate genes: MATN1, EPB41, growth hormone receptor, COL2A1, COL1A1, MYO1H, DUSP6, ARHGAP21, ADAMTS1, FGF23, FGFR2, TBX5, ALPL, HSPG2, EVC, EVC2, the HoxC gene cluster, insulin-like growth factor 1, PLXNA2, SSX2IP, TGFB3, LTBP2, MMP13/CLG3, KRT7, and FBN3. On the other hand, MYH1, MYH2, MYH3, MYH7, MYH8, FOXO3, NFATC1, PTGS2, KAT6B, HDAC4, and RUNX2 expression is suspected to be involved in the epigenetic regulations behind the mandibular prognathism phenotype.

A Three-Dimensional Study of Midfacial Changes Following Le Fort II Distraction With Zygomatic Repositioning in Syndromic Patients.

Le Fort II distraction with zygomatic repositioning introduced the ability to restore central midfacial height and convexity independent of changes in orbital morphology. This study analyzes midfacial and orbital morphology before and after Le Fort II distraction with zygomatic repositioning.All patients who underwent Le Fort II Distraction with zygomatic repositioning between 2013 and 2015 were included. Two- and 3-dimensional measurements were made using 3dMD Vultus software to assess canthal tilt, nasolabial angle, ratio of midfacial to lower facial height, and absolute change in nasal length. Presence of an open bite and Angle classification were assessed before and after surgery.Four patients underwent segmental midface advancement using Le Fort II distraction with zygomatic repositioning. Associated diagnoses included Apert syndrome, Goldenhar syndrome, and achondroplasia. Changes in facial dimensions included: 3.19° improvement in canthal tilt (range -4.7° to 8.4°), 9° change in nasolabial angle (range -1.0° to 19°), and 0.69 cm increase in absolute nasal length (range 0.2-0.94 cm). Mean ratio of midfacial to lower facial height was 0.79 preoperatively and 0.89 postoperatively. Preoperatively, all patients demonstrated Angle class III with 3 of 4 patients demonstrating anterior open bite. All achieved closure of open bite and demonstrated class I or II occlusion. No complications were observed.Le Fort II distraction with zygomatic repositioning resulted in normalization of midfacial soft tissue landmarks. This form of advancement demonstrates the ability to selectively improve midfacial height and canthal tilt while restoring normal occlusion.

[Evaluation of the correction of the skeletal class III malocclusion by distalization of the whole mandible dentition with micro-implant anchorage].

OBJECTIVE: To evaluate the clinical effect of distalizing mandibular dentition with micro-implant in patients with skeletal class III malocclusion. METHODS: In the study, 20 patients with skeletal class IIImalocclusion were selected. They are consist of 8 males and 12 female with an age range from 16 to 38 years old and an average age of (21.5±5.6) years.They were treated with straight wire technique and the implant were inserted into the mandibular external oblique line to distlize the lower dentition to a class I molar relationships. Cephalometrics films were taken before and after treatment. The changes of hard tissue and soft tissue were analyzed by evaluating 26 measurement measurements. RESULTS: Class I molar relationships were achieved, and the profile were improved after treatment. ANB increased by (0.80±1.02) °,Wits increased by (1.67±1.74) mm,after treatment (P<0.05). The lower dentition were significantly retracted after treatment with L1-NB distance decreased by(2.64±1.50) mm, P<0.05; the mesial buccal cusp and mesial root of the lower first molars were retracted by (3.26±1.95) mm and (0.79±1.27) mm respectively (P<0.05); the mesial buccal cusp of the lower second molars were retracted by (3.06±1.80) mm (P<0.05). After treatment, mandibular teeth got up-righted distally. From incisors to molar, L1/MP, L5/MP, L6/MP, L7/MP angle decreased by (6.37±8.53)°, (10.59±8.50)°, (11.48±7.22)°, (15.72±7.16)°on average respectively (P<0.05), all of those changes had the statically significant effects. Soft tissue change after treatment, the distance from lower lip to esthetic plane were decreased by (1.70±1.59) mm on average (P<0.05). CONCLUSION: Distalizing mandibular dentition with micro-implant can get an satisfying result in patients with skeletal class III malocclusion, the lower teeth were retracted by controlled tipping movement.

Mandibular Body Resection and Setback for Severe Malocclusion in Lymphatic Malformations.

Extensive lymphangiomas of the facial skeleton result in deforming forces leading to ongoing masticatory, speech, oral hygiene, and airway problems. This paper presents a small series of patients with severe mandibular overgrowth secondary to lymphatic malformations. Following debulking of the malformations and tongue reductions, the authors describe the results of their treatment with bilateral mandibular body resections and setback. The authors' results suggest that severe functional impairment from deforming malformations can be addressed in childhood with orthognathic surgery. Improved occlusion, oral closure, and airway opening can be achieved using this procedure.

A New Designed Expander Supported by Spike Miniscrews With Enhanced Stability.

INTRODUCTION: This article represents a new design of expander-spike expander-to correct transverse maxillary deficiency. This new type appliance is easy to fabricate, more hygienic, and less soft-tissue irritation because of elimination of acrylic plate. In addition, because of the position of mini-implant, it can provide a relatively parallel alveolar expansion, compared with other types of expander. MATERIALS AND METHODS: The spike expander consists of 2 parts: 4 spike screws and an expansion screw. Four spike screws were placed on the palatal slope. After installation of the spike screws, based on the position of spike screw, the extension arms of expansion screw were bended on the cast model, and connected to the spike screws by adding resin. The expansion screw was turned once a day (0.25 mm/d), and the process was terminated at 6 weeks. RESULTS: The stability and design of the spike screw enable widening of maxilla easier. Compared with other expander, spike expander reduces the forces being placed directly on teeth, which can maximize skeletal expansion, minimize dental tipping, produce a relatively parallel expansion, and reduce soft-tissue irritation caused by acrylic pads. Furthermore, the teeth can be aligned and leveled simultaneously using the fixed appliance because teeth are free of contact by the expander. And the best point for spike expander is that it is simply fabricated and removed. CONCLUSIONS: The design of spike expander is combining spike screws and an expansion screw, which can provide a good and easy treatment method for transverse maxillary deficiency.

The relationship between Angle type of occlusion and recorded Bennett angle values.

STATEMENT OF PROBLEM: The Bennett angle can be an important parameter to accurately record and program into an articulator during restorative procedures. Few data exist regarding the impact and association of a patient's occlusion types on their recorded Bennett angle values. PURPOSE: The purpose of this in vivo study was to investigate the effect of occlusion type on recorded Bennett angle values. MATERIAL AND METHODS: This study included 98 participants (26.0 ±5.2 years) divided into 4 study groups: Angle class I; Angle class II, division 1; Angle class II, division 2; Angle class III. All recordings were obtained using an ultrasound mandibular recording device with 6 degrees of freedom and a clutch was attached to the mandible. On each participant, 3 protrusive, 3 left laterotrusive, and 3 right laterotrusive movements were recorded. The recording device's software automatically calculated Bennett angle for each participant's left and right mandibular fossae and the data were statistically analyzed. RESULTS: One-way ANOVA did not show significant differences among different Angle classes of occlusion for the Bennett angle values. The average Bennett angle value for all participants was 7.7 degrees. CONCLUSIONS: The results of this study suggest that different Angle occlusion classifications do not appear to have an impact on recorded Bennett angle values. The average Bennett angle value in this study was found to be approximately 8 degrees. This information should be considered when programming average values into an articulator with respect to desired negative error (shorter cusp) during restoration fabrication.

Wear-time recording during early Class III facemask treatment using TheraMon chip technology.

Successful intervention in a developing Class III malocclusion with facemask protraction therapy depends on a patient's ability to adhere to the recommendations for duration of appliance wear. In this article, we report the introduction of a novel approach for tracking of the duration of application of a protraction facemask, with the incorporation of a "FaceMon" sensor (TheraMon, microelectronic system; MC Technology GmbH, Hargelsberg, Austria) to track wear time. A 9-year-old boy with a Class III malocclusion was successfully treated with a modified alternate rapid maxillary expansion and constriction protocol and intermittent application of a hybrid hyrax-protraction facemask combination. The average duration of wear of the facemask was measured at 10.8 hours per day. The use of an objective measuring device may have implications for the development of treatment strategies, since patient responses may be able to calibrated in relation to compliance.

Craniofacial characteristics of children with mild hypodontia.

INTRODUCTION: The aim of our study was to evaluate the craniofacial characteristics of children with mild hypodontia using conventional and principal component (PC) analysis. METHODS: We used radiographic images of 124 children (8-12 years old) with up to 4 missing teeth (55 boys, 69 girls) and of 676 reference children (365 boys, 311 girls) from the Rotterdam Generation R Study and the Nijmegen Growth Study in The Netherlands. Fifteen cephalometric measurements of children with hypodontia were compared with those of the reference children. Moreover, cephalometric parameters were combined into standardized PC scores using PC analysis, and the components were compared between the 2 groups. RESULTS: PC analysis showed common dental characteristics for all types of hypodontia: a significant increase of the interincisal angle, and decreases of the maxillary and mandibular incisor angles. Other findings were consistent when both methods were applied: (1) anterior hypodontia was significantly associated with the high-angle (hyperdivergent) craniofacial pattern, (2) the tendency toward a Class III malocclusion was identified in maxillary hypodontia, and (3) we observed a significant reduction of lower posterior facial height in children with posterior and mandibular hypodontia. CONCLUSIONS: Our findings suggest that children with mild hypodontia have distinctive skeletal and dental features.

Diagnosis and conservative treatment of skeletal Class III malocclusion with anterior crossbite and asymmetric maxillary crowding.

A man, aged 28 years 9 months, came for an orthodontic consultation for a skeletal Class III malocclusion (ANB angle, -3°) with a modest asymmetric Class II and Class III molar relationship, complicated by an anterior crossbite, a deepbite, and 12 mm of asymmetric maxillary crowding. Despite the severity of the malocclusion (Discrepancy Index, 37), the patient desired noninvasive camouflage treatment. The 3-Ring diagnosis showed that treatment without extractions or orthognathic surgery was a viable approach. Arch length analysis indicated that differential interproximal enamel reduction could resolve the crowding and midline discrepancy, but a miniscrew in the infrazygomatic crest was needed to retract the right buccal segment. The patient accepted the complex, staged treatment plan with the understanding that it would require about 3.5 years. Fixed appliance treatment with passive self-ligating brackets, early light short elastics, bite turbos, interproximal enamel reduction, and infrazygomatic crest retraction opened the vertical dimension of the occlusion, improved the ANB angle by 2°, and achieved excellent alignment, as evidenced by a Cast Radiograph Evaluation score of 28 and a Pink and White dental esthetic score of 3.

Occlusal rehabilitation of pseudo-class III patient.

To treat a patient with anterior crossbite, the clinician should first assess if it is a genuine class III or a pseudo-class III malocclusion. Cephalometric analysis is important; however, registering a patient's centric relation (CR) is simple, quick, and costless and can play a decisive role in a differential diagnosis for this type of patient profile. This clinical report depicts a patient clinically diagnosed as class III. After mandible manipulation in CR, it was noted that the patient in question was a pseudo-class III. The treatment was based on the pseudo-class III diagnosis. Therefore, the patient was rehabilitated by occlusal adjustments and conventional and implant-supported prostheses and without the need for invasive orthognathic surgery.

Unilateral condylar hyperplasia: diagnosis, clinical aspects and operative treatment. A case report.

BACKGROUND: Condylar hyperplasia of the mandible is an uncommon idiopathic disorder of the jaw characterised by increased volume of the condyle, unilaterally or bilaterally, leading to facial asymmetry, mandibular deviation, malocclusion and articular dysfunction. CASE REPORT: The authors present one case of unilateral condylar hyperplasia of a 16-year-old patient affected by severe facial asymmetry. Conventional X-rays examinations, multislice spiral CT and bone SPECT were used for the final diagnosis of primary condyle hyperplasia. The patient was treated with a combined orthodontic and surgical approach. CONCLUSION: Treatment of condylar hyperplasia with a combined orthodontic and surgical approach including condylectomy yield good aesthetic and functional outcomes.

Keep an Eye Out for the Bifid Uvula: A Case Report.

The incidence of submucous cleft palate is between 1:1250-1:6000. It is important for this relatively silent deformity to be identified early and referred appropriately as a delay in diagnosis may affect the patient's quality of speech in the long-term. This paper presents a case of submucous cleft palate which was diagnosed late (age 14). Nevertheless, by the appropriate intervention of the multidisciplinary cleft team, the patient was treated successfully. Clinical Relevance. Dentists and doctors need to be aware of the signs and symptoms associated with submucous cleft palate so that they can refer the patient to an appropriate specialist centre for further investigation and treatment. Moreover, patients with this condition are shown to have a higher incidence of dental abnormalities, such as hypodontia and peg-shaped laterals.

Outcomes of arthrocentesis for the treatment of internal derangement pain: with or without corticosteroids?

PURPOSE: Arthrocentesis (AC) is an acceptable treatment modality in the treatment of internal derangement (ID) pain. This study evaluated outcomes of AC on pain relief of ID pain with or without corticosteroids. MATERIALS AND METHODS: This single-blind clinical trial was conducted on 60 patients with ID pain who were randomly assigned to 2 groups (30 in each group) for AC. The AC of the upper joint space was then performed by using Ringer lactate under local anesthesia in both groups. In the second group, the procedure was followed by the administration of a single-dose intra-articular dexamethasone (8 mg). Assessments were made at baseline (T0), 1 month (T1), and 6 months (T6) after AC; pain, maximum mouth opening, and joint sounds before and after treatment up to 6 months were evaluated. Pain severity was documented according to Visual Analogue Scale. Age, sex, and skeletal maxillomandibular relationship were considered as variable factors, and irrigation with or without corticosteroids was a predictive factor of the study. Pain, click, and maximum mouth opening were other assessment outcomes of the study. RESULTS: Comparison of age, sex, and skeletal relationship did not show any significant differences between the 2 groups. Results did not demonstrate any difference for click between the 2 groups. Comparison of pain severity in T0, T1, and T2 between the 2 groups did not show any significant differences (P < 0.05). The repeat measure test revealed a significant change in T0, T1, and T2 for both groups (P < 0.001). MMO significantly changed between T0 and T1 and T0 and T6 in the 2 groups without any significant differences between them. CONCLUSIONS: The AC is an effective procedure for a short-term reduction of pain in temporomandibular disorder cases. It seems that AC using Ringer solution with or without corticosteroids may have the same effect on pain relief.

Facial asymmetry with enlarged frontal sinus and hyperplasia of the cranial, nasal, and mandible bones.

The conditions of facial asymmetry are caused by congenital or acquired diseases, and several unclassifiable syndromes with unknown etiologies exist. In this report, a case of facial asymmetry with enlarged frontal sinus and hyperplasia of the frontal cranial bone and nasal bone is presented. Although the etiology of the facial malformation was clear, it was thought that the cause of the enlarged frontal sinus was related to the unidentified bony hyperplasia and facial asymmetry related to hemimandibular hyperplasia.

Transposition of maxillary canine to central incisor site: aetiology, treatment options and case report.

Dental transposition is relatively infrequent anomaly of the developing dentition. This article focuses on canine transposition and explores the aetiology, diagnosis and treatment of this challenging anomaly. Specifically, the management of a case of canine transposition involving an unerupted maxillary central incisor is described.

Early orthodontic treatment: a new index to assess the risk of malocclusion in primary dentition.

AIM: A new index targeted on the risk of malocclusions in primary dentition, called Baby-ROMA (Risk Of Malocclusion Assessment) index, was set up to assess risks/benefits in early orthodontic therapies. The Baby-ROMA index was designed from the observation that some of the malocclusion signs, observed in primary dentition, can worsen with growth, others remain the same over time and others can even improve. Therefore it would be important to classify the malocclusions observed at an early stage on a risk- based scale. MATERIALS AND METHODS: The reliability of the index was tested on 200 children, referred by their paediatricians to two different Orthodontic Departments, aged 4-6 years and in full primary dentition. The children were evaluated by two operators, both trained and calibrated on the use of the Baby-ROMA index. RESULTS: The K test showed a high reproducibility of the index. It is shown that 50% of patients presented malocclusion and crossbite had the highest prevalence, followed by tooth decay and early loss of deciduous teeth and negative overjet. CONCLUSION: The Baby-ROMA index was helpful to assess the severity of malocclusion and the timing for orthodontic treatment in very young patients (primary teeth).