[Influence of Sociodemographic Factors on Type of and Stage at Diagnosis in Breast Cancer]. / Zum Einfluss soziodemografischer Faktoren auf die Art der Verdachtsdiagnosestellung und das Tumorstadium bei Erstdiagnose von Brustkrebs.

This study examines the influence of sociodemographic factors on the type of and stage at diagnosis in breast cancer in Germany. METHOD: As part of the certification of the breast cancer centers by the German Cancer Society (DGK), the Institute of Medical Sociology, Health Services and Rehabilitation Science (IMVR) conducted nationwide post-stationary postal patient surveys (n=852). The influence of sociodemographic factors on the type of diagnosis and on the stage at diagnosis were each analyzed using a multinomial logistic regression. RESULTS: 45.5% palpated the tumor by themselves, 33.4% were diagnosed by mammography screening and 16.6% by gynecological check-up. Being diagnosed by screening was associated with an early stage cancer. Furthermore, breast cancer patients without private health insurance or with a low educational level were less likely to be diagnosed by a gynecological check-up. Patients within screening age (50-69) had higher odds for an early stage breast cancer. Patients with a low educational level had lower odds for an early stage breast cancer. CONCLUSION: Fifty percent of the breast cancer patients were not diagnosed by screening. Mammography screening appears to be more sensitive in detecting early stage cancer, since we found an association between diagnosis by screening and an early stage cancer. Age outside of the screening range and a low educational level might be risk factors for an advanced stage breast cancer. High screening rates, especially for these risk groups, seem to be important for early detection of breast cancer.

Evaluation of ultrasonic and conventional surgical techniques for genioplasty combined with two different osteosynthesis plates: a cadaveric study.

OBJECTIVES: The aim of this study was to compare genioplasties performed using traditional saw or piezosurgery combined with different osteosynthesis plates. MATERIALS AND METHODS: Thirty-two genioplasties were first performed on fresh human cadavers using a saw or piezosurgery, followed by chin osteosynthesis with bending or pre-shaped plates. The time required for osteotomy and plate fixation was measured, and the suprahyoid pedicle was inspected. RESULTS: The mean time required was 204 s (SD 43) with the saw and 52 s (SD 67) with piezosurgery. Osteosynthesis fixation time was 100 s (SD 31) for pre-shaped plates and 124 s (SD 24) for individual plates. Statistical differences were found between both osteotomy techniques (p < 0.001) and osteosynthesis plates (p = 0.025). Injuries of the suprahyoid muscle pedicle were found in 10/16 saw cases and 3/16 piezosurgery cases (p = 0.012). CONCLUSIONS: Although piezosurgery is more time consuming compared with saw osteotomy, it is still adequate in time and allows a reduction of the suprahyoid pedicle injuries. Therefore, piezosurgery seems to be a viable alternative technique for genioplasty. From a clinical point of view, the time difference for osteosynthesis fixation has no significance. CLINICAL RELEVANCE: The time taken for ultrasonic surgery is suitable for clinical use and leads additional to less damage to the suprahyoid pedicle.

Quality of orthodontic care-A multicenter cohort study in a German convenience sample : Part 2: Cross-sectional patient-reported outcomes after orthodontic treatment.

OBJECTIVES: In light of the growing interest in orthodontic care and its effectiveness in Germany, part 2 of this multicenter cohort study evaluated patient-reported outcomes such as oral health-related quality of life (OHRQoL), oral hygiene habits, oral health beliefs, and potential influencing factors. METHODS: Of 586 patients screened from seven German study centers, data from 343 patients were analyzed for this part of the study. At the end of their orthodontic treatment, study participants filled out a questionnaire of either the German long version of the Oral Health Impact Profile (OHIP-G 49) or the German short version of the Child Oral Health Impact Profile (COHIP-19), depending on their age, as well as questions about their oral hygiene behavior and beliefs. Patient-, treatment- and occlusion-related factors were analyzed to account for potential influencing factors with regard to patients' OHRQoL after orthodontic treatment. RESULTS: In all, 222 study participants filled out the OHIP-based and 121 the COHIP-based questionnaire. The mean OHIP-G 49 score was 12.68 and the mean OHIP-G 14 score was 3.09; the mean COHIP-19 score was 6.52 (inverted score 69.48). For OHIP-G 49 scores, a nonsignificant trend towards a higher score for male patients (14.45 vs 11.54; p = 0.061) was detected, while this trend was inverse for the COHIP-19 scores, i.e., female patients reported more impairment (total score 6.99 vs. 5.84; p = 0.099). Analyses suggested a trend towards better OHRQoL for patients who classified for the Peer Assessment Rating (PAR) Index improvement rate group 'greatly improved' as well as for nonsmokers. Oral hygiene habits and beliefs after orthodontic treatment were estimated to be good. CONCLUSION: In this German cohort, OHRQoL proved to be good and was rather unimpaired after orthodontic treatment. Furthermore, self-reported oral hygiene behavior and oral health beliefs represented good health awareness.

Therapeutic vaccination with recombinant adenovirus reduces splenic parasite burden in experimental visceral leishmaniasis.

Therapeutic vaccines, when used alone or in combination therapy with antileishmanial drugs, may have an important place in the control of a variety of forms of human leishmaniasis. Here, we describe the development of an adenovirus-based vaccine (Ad5-KH) comprising a synthetic haspb gene linked to a kmp11 gene via a viral 2A sequence. In nonvaccinated Leishmania donovani-infected BALB/c mice, HASPB- and KMP11-specific CD8(+) T cell responses were undetectable, although IgG1 and IgG2a antibodies were evident. After therapeutic vaccination, antibody responses were boosted, and IFNγ(+)CD8(+) T cell responses, particularly to HASPB, became apparent. A single vaccination with Ad5-KH inhibited splenic parasite growth by ∼66%, a level of efficacy comparable to that observed in early stage testing of clinically approved antileishmanial drugs in this model. These studies indicate the usefulness of adenoviral vectors to deliver leishmanial antigens in a potent and host protective manner to animals with existing L. donovani infection.

Discovery of substituted benzyl tetrazoles as histamine H3 receptor antagonists.

A series of potent and subtype selective H3 receptor antagonists containing a novel tetrazole core and diamine motif is reported. A one-pot multi-component Ugi reaction was utilised to rapidly develop the structure-activity relationships (SAR) of these compounds. Optimisation for liver microsome stability (t(1/2)>60 min), minimal CYP inhibition (IC(50)>50 microM) and high cell permeability (Caco-2 P(app) >20x10(-6) cm/s) identified several compounds with drug-like properties.

Three-dimensional evaluation of bracket placement accuracy and excess bonding adhesive depending on indirect bonding technique and bracket geometry: an in-vitro study.

BACKGROUND: This study aimed at comparing bracket placement and excess bonding adhesive depending on different indirect bonding (IDB) techniques and bracket geometries. METHODS: Four hundred eighty brackets without hook (WOH) and 360 with hook (WH) were placed on 60 plaster models. Three IDB techniques were tested: polyvinyl-siloxane vacuum-form (PVS-VF), polyvinyl-siloxane putty (PVS-putty), and translucence double-polyvinyl-siloxane (double-PVS). PVS-VF and PVS-putty were combined with chemically, and double-PVS was combined with light cured bonding adhesive. Virtual images of models before and after bracket transfer were generated, and computerized images were compared. Linear, angular deviations, and excess bonding adhesive were measured. RESULTS: Linear differences between the three groups were obtained for PVS-VF (WH: 1.08, SD 0.50 mm; WOH: 0.86, SD 0.25 mm), PVS-putty (WH: 0.73, SD 0.51 mm; WOH: 0.58, SD 0.28 mm), and double-PVS (WH: 0.65, SD 0.45 mm; WOH: 0.59, SD 0.33 mm) (P < 0.001). Hooks affected bracket placement accuracy in PVS-VF (P < 0.001) and PVS-putty (P = 0.029). Angular differences were observed for brackets WOH between the PVS-VF (0.64, SD 0.48°) and double-PVS group (0.92, SD 0.76°) (P < 0.001) and within double-PVS group (WH: 0.66, SD 0.51° vs. WOH: 0.92, SD 0.76°, P < 0.001). Highest amount of excess adhesive was obtained for PVS-putty group (WH: 6.54, SD 5.31 mm 2). CONCLUSIONS: The double-PVS group revealed promising results with respect to transfer accuracy, whereas the PVS-VF group provided least excess bonding adhesive. Basically, hooks lead to lower precision and higher excess bonding adhesive. PVS trays for IDB generate high bracket placement accuracy. PVS-putty is the easiest to handle with and also the cheapest, but leads to large excess bonding adhesive, especially in combination with hooked brackets or tubes.

Effect of the pterygomaxillary disjunction on surgically assisted rapid palatal expansion in context of orthodontic treatment.

OBJECTIVE: This retrospective study analyzed the dentoalveolar effects of pterygomaxillary disjunction (PMD) in surgically assisted rapid palatal expansion (SARPE) after orthodontic treatment. STUDY DESIGN: Virtual study casts before and after orthodontic treatment involving SARPE were analyzed in 12 patients without (-) PMD and 15 patients with (+) PMD. Linear and angular measurements and maximum deviations on the alveolar ridge and hard palate were determined. RESULTS: Dental arch widths in the first molars of the (-) and (+) PMD groups increased to 6.07 ± 2.11 mm and 6.61 ± 2.33 mm (P = .96) and the corresponding axial angles increased to 0.34 ± 9.45 degrees and 2.39 ± 9.59 degrees (P = .58), respectively. The palatal angles changed by about 0.10 ± 11.50 degrees and 1.74 ± 14.56 degrees (P = .75) in the (-) and (+) PMD groups and the maximum labial deviations at the alveolar ridge were 3.04 ± 0.76 mm and 3.22 ± 1.16 mm (P = .65) for the (-) and (+) PMD groups, respectively. Statistically significant differences were found before and after surgery (P < .04), but no significant differences were observed in PMD after orthodontic treatment. CONCLUSIONS: SARPE led to a significant transverse expansion, and the dental effects were more than the skeletal effects. We did not find a significant difference between both surgical techniques with regard to the anterior and posterior parts of the maxilla or the corresponding dentition.

Fragment-based discovery of BACE1 inhibitors using functional assays.

Novel nonpeptidic inhibitors of beta-secretase (BACE1) have been discovered by employing a fragment-based biochemical screening approach. A diverse library of 20000 low-molecular weight compounds were screened and yielded 26 novel hits that were confirmed by biochemical and surface plasmon resonance secondary assays. We describe here fragment inhibitors cocrystallized with BACE1 in a flap open and flap closed conformation as determined by X-ray crystallography.

Influence of physician evaluation portals on orthodontist selection by patients.

OBJECTIVE: This survey aimed to determine the influence of physician evaluation portals (PEP) on a patient's choice of physicians, particularly orthodontists. MATERIALS AND METHODS: Questionnaires were used to collect sociodemographic data, reasons for orthodontist selection, type of Internet use, as well as information on the knowledge, use and evaluation of 14 popular PEPs. A total of 506 questionnaires were evaluated, and a descriptive statistical evaluation was conducted using the χ2 test. RESULTS: The majority of the respondents selected orthodontists on the basis of personal recommendations by other physicians (35%), family/friends (33%) or patient referral (14%). Currently, the most popular portals in Germany, which are mostly found through Internet searches, are jameda.de (36%) and arztauskunft.de (19%). A total of 5% of the respondents have already used a PEP to evaluate a physician. Moreover, 70% of the respondents described PEPs as helpful, 28% as recommendable and 2% use PEPs regularly. Knowledge of PEPs is correlated with the level of educational attainment (p = 0.024) and the frequency of Internet use (p < 0.001). CONCLUSION: On the selection of healthcare providers, particularly orthodontists, PEPs have little influence. Patients select physicians on the basis of personal recommendations. Physicians' concerns about negative evaluations on PEPs are unfounded given the low level of awareness of PEPs by the general populace.

Spatial agreement of demineralized areas in quantitative light-induced fluorescence images and digital photographs.

OBJECTIVES: Previous work has shown qualitatively that detection of demineralized tooth areas (white spot lesions, WSLs) is more reliable in digital photographs (DP) as in quantitative light-induced fluorescence (QLF) images. Based on non-rigid, multimodal image registration, we now quantitatively compare manual and automatic markings in both modalities. METHODS: After braces removal, pairs of DP and QLF were acquired from 124 teeth of 31 patients. Three experienced raters marked the WSL on both DP and QLF images, each of which was presented twice in randomized order. For each tooth and each modality, a ground truth (GT) was established using the simultaneous truth and performance level estimation algorithm on the total of six manual markings per image. DP and QLF image pairs were spatially registered, by aligning the outline of the tooth area in DPs to that of the corresponding tooth area in QLF. Between all pairs of markings for all teeth, position and size were compared quantitatively by the Dice coefficient and the novel coefficient of inclusion. RESULTS: Our hypotheses: (i) the clinical inspection supported by DP is more sensitive to WSL as that by QLF, disregarding whether the automatic analysis or the experts' manual assessment of QLF is applied, and (ii) detected lesions in QLF are included in those of DP, were confirmed and not confirmed, respectively. CONCLUSION: DP and QLF are valuable methods to detect WSL in demineralized teeth. Combining both modalities can provide additional information on early lesion assessment.

Biomechanical properties of CAD/CAM-individualized nickel-titanium lingual retainers: an in vitro study.

PURPOSE: This study aimed to determine and compare the mechanical properties of novel CAD/CAM(computer-aided design/manufacturing)-individualized nickel-titanium (NiTi) and conventional twisted wires. METHODS: Seven NiTi wires (angular, 0.20â€¯× 0.20 mm up to 0.50â€¯× 0.50 mm) and two twisted steel wires (round, 0.40 mm and 0.44 mm) were investigated in three-point (3PBT) and four-point bending tests (4PBT) using the Orthodontic Measurement and Simulation System. All wires were loaded up to a distance of 3.3 mm, and resulting forces were measured. Additionally, in the biomechanical test (BMT), CAD/CAM-individualized NiTi retainers (0.35â€¯× 0.35 mm) were subjected to intrusive and extrusive deformation of 0.1, 0.2, and 0.4 mm. RESULTS: For twisted wires, typical plastic deformations were found in 3PBT (0.40 mm: 0.3 mm; 0.44 mm: 0.4 mm), and maximum resulting forces for these reached 1.3 N and 3.2 N for the 0.40 mm and 0.44 mm wires, respectively. Corresponding values in the 4PBT totaled 0.8 N for the 0.40 mm and 1.9 N for the 0.44 mm twisted wire. The NiTi samples showed plastic deformations in the 3PBT for the 0.25â€¯× 0.25 mm dimension and in 4PBT for the 0.35 mmâ€¯× 0.35 mm version. At a deflection of 1.5 mm, both tests revealed significantly different forces for the NiTi wires of different dimensions (p ≤ 0.001). In the BMT, no remarkable loading plateau or plastic deformation was observed. The resulting forces were significantly higher for extrusive than for intrusive deformation (p ≤ 0.001). CONCLUSIONS: Individualized NiTi retainers feature specific elasticity and dimensional stability, and more deflection is necessary to achieve permanent deformations. The CAD/CAM production process did not significantly influence the biomechanical properties of the NiTi wires.

Quantitative light-induced fluorescence images and digital photographs - Reproducibility of manually marked demineralisations.

OBJECTIVE: Hard tooth tissue demineralisation is an undesirable side effect of orthodontic treatment with fixed appliances. Whereas both clinically and in digital photographs (DP), demineralisations appear as white spot lesions, WSLs appear as dark areas when quantitative light-induced fluorescence (QLF) imaging is used. This study aims at comparing the reproducibility of the detection of decalcified tooth areas in DP and QLF. MATERIALS AND METHODS: DP and QLF pairs were acquired from 139 teeth of 32 patients after braces removal. Three raters manually marked the decalcified area on both DP and QLF images. The markings were repeated after 2 weeks. A ground truth was estimated for each tooth and modality using the simultaneous truth and performance level estimation (STAPLE) algorithm. The Dice coefficients (DC) of each rater marking to the ground truth were calculated for all teeth and modalities to quantify the spatial agreement. A three-way repeated measures analysis of variance (ANOVA) was used to compare the means of the DCs for both modalities ([Formula: see text]). Intra-observer and intercycle variabilities were assessed comparing the means across the raters and the cycles for both modalities. RESULTS: ANOVA revealed a statistical significant difference between the modalities [[Formula: see text], [Formula: see text]]. The standard deviation of the DC for the photographs are lower than those for the QLF images. Intra-observer and intercycle differences are rather small as compared to the intermodality differences. CONCLUSIONS: The results indicate a higher spatial reproducibility in identifying a decalcified area on a tooth surface using visual inspection of DP rather than QLF images.

Fracture patterns after bilateral sagittal split osteotomy of the mandibular ramus according to the Obwegeser/Dal Pont and Hunsuck/Epker modifications.

The aim of this study was to compare the fracture patterns after sagittal split osteotomy according to Obwegeser/Dal Pont (ODP) and Hunsuck/Epker (HE), as well as to investigate the relationship between lateral bone cut ending or angle and the incidence of unfavorable/bad splits. Postoperative cone-beam computed tomograms of 124 splits according to ODP and 60 according to HE were analyzed. ODP led to 75.8% and HE led to 60% lingual fractures with mandibular foramen contact. Horizontal fractures were found in 9.7% and 6.7%, respectively, and unfavorable/bad splits were found in 11.3% and 10%, respectively. The lateral osteotomy angle was 106.22° (SD 12.03)° for bad splits and 106.6° (SD 13.12)° for favorable splits. Correlations were found between favorable fracture patterns and split modifications and between buccal ending of the lateral bone cut and bad splits (p < 0.001). No relationship was observed between split modifications (p = 0.792) or the osteotomy angle (p = 0.937) and the incidence of unfavorable/bad splits. Split modifications had no influence on the incidence of unfavorable/bad splits, but the buccal ending of the lateral bone cut did have an influence. More lingual fractures with mandibular foramen contact are expected with the ODP modification. The osteotomy angle did not differ between favorable and bad splits.

[Uprighting of a tipped lower second molar with the aid of a microscrew anchorage. A case report]. / Aufrichtung eines gekippten unteren zweiten Molaren mit Hilfe von Mikroschrauben-verankerung. Ein Fallbericht.

Titanium microscrews for orthodontic anchorage purposes have been developed in different designs and dimensions by a number of manufacturers. Whereas conventional implants need a relatively extensive bone supply and the insertion sites are limited, microscrews offer a more flexible range of applications. They also offer crucial advantages such as simple, atraumatic insertion and removal, a minimum patient stress and a favourable cost-benefit ratio. In the present case report the successful orthodontic uprighting of a tipped second lower molar using a microscrew demonstrated.

Bony contact area and displacement of the temporomandibular joint after high-oblique and bilateral sagittal split osteotomy: a computer-simulated comparison.

The most common way to move the mandible during orthognathic surgery is by bilateral sagittal split osteotomy (BSSO). The high-oblique sagittal split osteotomy (HSSO) is an alternative, although its use is limited by potential complications, mainly to do with the position of the condyle and reduced contact with bone. The aim of this study was to find out the optimal intercondylar distance and area of contact with the surface of the bone for mandibular advancement and setback in BSSO and HSSO. Data from computed tomographic (CT) images from 40 patients were loaded into special planning software, and virtual operations done for mandibular advancement and setback at 3, 5, 8, and 10mm using BSSO and HSSO, which resulted in 640 individual mandibular displacements. The resultant area of bony contact and intercondylar distance were calculated by the software. The mean (SD) areas of contact with the bony surface after 10mm advancement for HSSO and BSSO were 193.94 (63.76) mm(2) and 967.92 (229.21) mm(2), respectively, and after 10mm setback 202.64 (62.30) mm(2) and 1108.86 (247.38) mm(2). The mean corresponding intercondylar distance after maximum advancement were 86.76 (6.40) mm and 86.59 (6.24) mm, and after maximum setback 74.90 (5.73) mm and 73.06 (6.06) mm. There were significant differences between the two for the area of contact with the surface at each displacement distance (p<0.001), but not for intercondylar distance. A larger area of bony contact can be expected at any displacement distance for BSSO, so the changes in intercondylar distance should not be considered when deciding which osteotomy to select.

Three-dimensional effects of pterygomaxillary disconnection during surgically assisted rapid palatal expansion: a cadaveric study.

OBJECTIVE: The aim of this study was to investigate the influence of pterygomaxillary disconnection on the transversal expansion of the maxilla. STUDY DESIGN: Fifteen cadaver heads were used for surgically assisted rapid palatal expansion (SARPE), which was carried out twice on the same heads-with and without pterygoid disconnection. The maxillae were expanded by 10 mm by using a rapid palatal expander. Study models before and after both SARPE techniques were made and scanned by an oral scanner for virtual analysis by software. RESULTS: Performing pterygomaxillary disconnection during SARPE led to a decrease in the deviation between the incisor regions from 5.42 ± 1.13 mm to 4.05 ± 1.12 mm (P = .002) and an increase in the distance between second premolar regions from 2.63 ± 1.64 mm to 4.07 ± 2.01 mm (P = .040). CONCLUSIONS: SARPE without pterygomaxillary disconnection led to a V-shaped transverse expansion of the maxilla, whereas osteotomy of the pterygoid plates led to a parallel transverse expansion.

Light microscopic and SEM findings after orthodontic treatment--analysis of a human specimen.

AIM: The hard and soft tissue damage caused by orthodontic forces has so far, for obvious ethical reasons, been investigated in animal models primarily. However, the validity of these results as applied to humans remains controversial. The particular value of this study is that the maxilla of a young adult could be analyzed histologically. Thus it was possible to retrospectively study the effects of a routine orthodontic therapy using light microscopy. MATERIAL AND METHODS: The upper jaw of a 24-year-old patient was investigated. He had been in orthodontic treatment with a straight-wire-appliance using superelastic materials for 18 months. Both posterior segments were analyzed in the horizontal plane using the microsection method according to Donath (toluidine blue staining). Both central incisors were analyzed using a scanning electron microscope (SEM). The examination was performed qualitatively and histomorphometrically. RESULTS: 170 lateral root resorptions were found in the nine posterior teeth, while pressure sites and interference areas with the buccal and sinus cortical bone were predominantly affected. However, the extent of root resorption was minimal: mean length 979 +/- 766 microm, mean depth 208 +/- 133 microm. The lateral root erosions presented high repair potential: 55.6% of resorption length, and 28% of the depth were repaired in 76% of all lesions. CONCLUSION: The incidence of detected root resorptions seems high at first. However, the prognosis of the affected teeth is not critically impaired, due to the lesions' minor extent (length, depth) and their high repair capacity.

Influence of setback and advancement osseous genioplasty on facial outcome: A computer-simulated study.

The aim of this virtual study was to investigate the influence of angular deviation and displacement distance on the overlying soft tissue during chin genioplasty. Computed tomography data from 21 patients were read using ProPlan CMF software. Twelve simulated genioplasties were performed per patient with variable osteotomy angles and displacement distances. Soft-tissue deformations and cephalometric analysis were compared. Changes in anterior and inferior soft-tissue of the chin along with resultant lower facial third area were determined. Maximum average changes in soft-tissue were obtained anterior after 10-mm advancement about 4.19 SD 0.84 mm and inferior about -1.55 SD 0.96 mm. After 10-mm setback anterior -4.63 SD 0.56 mm and inferior 0.75 SD 1.16 mm were deviations found. The anterior soft tissue showed a statistically significant change with bony displacement in both directions independent of osteotomy angle (p < 0.001) and only after a 10-mm advancement with an angle of -5° significant differences at inferior soft-tissue were noted (p = 0.0055). The average area of the total lower third of the face was 24,807.80 SD 4,091.72 mm(2) and up to 62.75% was influenced. Advanced genioplasty leads to greater changes in the overlying soft tissue, whereas the affected area is larger after setback displacement. The ratio between soft and hard tissue movements largely depends on the displacement distance.

Limitations of osseous genioplasty in relation to the displacement distance: a computer-based comparative study.

OBJECTIVE: The aim of this study was to compare the contact surface area (CSA) between bony segments after performing 4 different osteotomy techniques for genioplasty. STUDY DESIGN: Virtual genioplasties were done in terms of sliding or chin-shield genioplasty and 1- or 2-tiered genioplasty on computed tomography (CT) data from 42 patients. Advancement or setback genioplasty was simulated at 3, 5, 8, and 10 mm. The resulting bony contact areas were calculated by using software. RESULTS: No statistically differences were found between both 2-tiered techniques at any displacement distance. Significant statistical differences were noticed between 1-tiered genioplasty and corresponding upper and lower osteotomy at 2-tiered genioplasty and between lower osteotomies of both 2-tiered techniques (P < .001). However, at a displacement distance of 8 mm, the CSA of the lower 2-tiered genioplasty was found to be larger than that of the corresponding after 1-tiered genioplasty (P < .001). CONCLUSIONS: From a displacement distance of 8 mm, a relatively larger CSA could be achieved after performing 2-tiered genioplasty technique.