Whole-Exome Sequencing Identified Two Novel Pathogenic Mutations in the PTCH1 Gene in BCNS.

Basal cell nevus syndrome (BCNS, OMIM 109400) is a familial cancer syndrome characterized by the development of numerous basal cell cancers and various other developmental abnormalities, including epidermal cysts of the skin, calcified dural folds, keratocysts of the jaw, palmar and plantar pits, ovarian fibromas, medulloblastomas, lymphomesenteric cysts, and fetal rhabdomyomas. BCNS shows autosomal dominant inheritance and is caused by mutations in the patched 1 (PTCH1) gene and the suppressor of the fused homolog (SUFU) gene. In a few cases, variants of patched 2 (PTCH2) have been found in patients who met the criteria for BCNS. In an investigation of 11 Hungarian families who fulfilled the diagnostic criteria for BCNS, whole-exome sequencing (WES) and multiplex ligation-dependent probe amplification (MLPA) identified two novel pathogenic variants (c.2994C>A; p.Cys998Ter and c.814_818del; p.Asn272SerfsTer11), one recently identified variant (c.1737_1745del p.Val580_Val582del), and three recurrent disease-causing variants of the PTCH1 gene with a diagnosis rate of 63.6%. Disease-causing variants were not found for the SUFU and PTCH2 genes. These applied methods could not fully elucidate the genetic background of all the BCNS cases that we investigated. To uncover the missing heritability of BCNS, whole-genome sequencing or an epigenetic approach might be considered in the future.

Guidance means accuracy: A randomized clinical trial on freehand versus guided dental implantation.

OBJECTIVES: A randomized clinical trial was conducted to compare all three known static guided surgery protocols (pilot, partial, and full) with each other and with freehand surgery in terms of accuracy, under the same conditions. MATERIAL AND METHODS: A total of 207 implants of the same brand and type were placed in 101 partially edentulous volunteers in need of implantation in the mandible or maxilla or both. All cases were digitally planned, and the comparison of the planned and actual implant positions was performed using a medical image analysis software with dedicated algorithms. The primary outcome variable was angular deviation (AD, degrees). The secondary outcome variables were coronal global deviation (CGD, mm), apical global deviation (AGD, mm), and voxel overlap (VO, %). RESULTS: AD showed stepwise improvement in significant steps as the amount of guidance increased. The highest mean AD (7.03° ± 3.44) was obtained by freehand surgery and the lowest by fully guided surgery (3.04° ± 1.51). As for the secondary outcome variables, all guided protocols turned out to be significantly superior to freehand surgery, but they were not always significantly different from each other. CONCLUSIONS: As for the comparison that this study sought to perform, it can be said that the static guided approach significantly improves the accuracy of dental implant surgery as compared to freehand surgery. Furthermore, the results suggest that any degree of guidance yields better results than freehand surgery and that increasing the level of guidance increases accuracy.

Surgical Management of Progressive Hemifacial Atrophy With De-Epithelialized Profunda Artery Perforator Flap: A Case Report.

Progressive hemifacial atrophy (PHA) is a rare disorder characterized by slow, unilateral atrophy of the soft tissues and bones of the craniofacial region. The defect becomes more pronounced with age, leading to esthetic and functional deficits. However, the proper timing and method of surgical reconstruction are still debated. The correction of this defect markedly influencing the quality of life of the patient can be achieved with less invasive to more invasive surgical approaches. A 21-year-old female patient with hemifacial atrophy and extensive alopecia presented to our clinic. Considering the body type and the expectations of the patient, a profunda artery perforator flap was applied for the reconstruction and esthetic improvement of the facial region. The facial asymmetry attenuated after the reconvalescence period. This case shows that in the up-to-date surgical treatment of severe PHA, the use of microvascular free flaps may provide a better approach when trying to achieve an acceptable esthetic result. This is the first time that a profunda artery perforator flap was used to restore facial asymmetry caused by PHA.

Effect of the Combination of Low-Speed Drilling and Cooled Irrigation Fluid on Intraosseous Heat Generation During Guided Surgical Implant Site Preparation: An In Vitro Study.

PURPOSE: Investigating the effect of the combination of low-speed drilling and cooled irrigation fluid on intraosseous temperature rise during guided and freehand implant surgery. MATERIALS AND METHODS: Bovine ribs were used as bone specimens. Grouping determinants were as follows: drill diameter (2.0, 2.5, 3.0, and 3.5 mm), irrigation fluid temperature (10°C, 15°C, and 20°C), and surgical method (guided and freehand). Drilling speed was 800 rpm. Results were compared with previous ones using 1200 rpm. Temperature measurements were conducted using K-type thermocouples. RESULTS: No mean temperature change exceeded 1.0°C if irrigation fluid cooled to 10°C was used, regardless of the drill diameter or the surgical method, with the highest elevation being 2.10°C. No significant reduction was measured when comparing groups using 15°C and 20°C irrigation fluids, regardless of both drill diameter and surgical method. CONCLUSION: The use of irrigation fluid being cooled to 10°C combined with low-speed drilling (800 rpm) seems to be a safe method for implant site preparation and drilling through a drilling guide in terms of temperature control.

[Epidermolysis bullosa: oral manifestations and their treatments]. / Az epidermolysis bullosa szájüregi tünetei és annak ellátása.

The aim of this comprehensive article is to provide guidelines for the daily treatment of patients with epidermolysis bullosa, thus contributing to the attainment of their higher quality of life through the improvement of their oral health. Moreover, it is our intention to facilitate the cooperation among Hungarian general practitioners, dermatologists and dentists. Relying on recent research findings of the international literature, we intend to help general practitioners or dermatologists treating epidermolysis bullosa patients on a daily basis by identifying symptoms that require consulting an oral professional on the one hand, and to present the most important prevention strategies and further treatments advised for dentists on the other. Focusing on various aspects of dental treatment, we specify how a dentist can treat the patient without causing additional wounds or pain, and what kinds of therapy are justified by this approach. Orv Hetil. 2017; 158(40): 1577-1583.

[Cooperation between the plastic surgery and the head & neck surgery departments in the treatment of unusual cases, Veszprém, Hungary, 2010-2015]. / Plasztikai sebészet és fej-nyak sebészet együttmuködése nem szokványos esetek ellátása kapcsán. Veszprém, 2010­2015.

INTRODUCTION: Handling problems in the head and neck region often requires a close cooperation between allied professions, just as in the challenging cases presented by us. Cases and methodology: With the first patient, we performed a radical surgery on the left side of the face due to recidivious basal cell carcinoma, followed by reconstruction using a Type I chimeric anterolateral thigh flap (ALT), while in the case of the second patient, we carried out a radical surgery on the right side of the face due to epithelial carcinoma and reconstruction with a Type I chimeric thoracodorsal flap. With our third patient, a reconstructive operation was performed due to left-sided congenital hemifacial microsomia, using a profunda artery perforator (PAP) flap. The fourth patient, due to the loss of the right hemi mandible as a result of an injury, went through a reconstructive procedure designed with Computer-Aided Design and Computer-Aided Manufacturing (CAD-CAM) technology, using a fibula free flap. RESULTS: All chosen reconstructive methods proved to be efficient and safe solutions in handling the problems. CONCLUSION: Through the cases presented, we intend to raise awareness of the importance of cooperation between maxillofacial and plastic surgery as well as of the ever-growing range of reconstructive opportunities through the flaps used.

[Navigation in implantology: Accuracy assessment regarding the literature]. / Navigáció alkalmazása az implantológiában: Összefoglaló áttekintés a pontossági adatok alapján.

Our objective was to assess the literature regarding the accuracy of the different static guided systems. After applying electronic literature search we found 661 articles. After reviewing 139 articles, the authors chose 52 articles for full-text evaluation. 24 studies involved accuracy measurements. Fourteen of our selected references were clinical and ten of them were in vitro (modell or cadaver). Variance-analysis (Tukey's post-hoc test; p < 0.05) was conducted to summarize the selected publications. Regarding 2819 results the average mean error at the entry point was 0.98 mm. At the level of the apex the average deviation was 1.29 mm while the mean of the angular deviation was 3,96 degrees. Significant difference could be observed between the two methods of implant placement (partially and fully guided sequence) in terms of deviation at the entry point, apex and angular deviation. Different levels of quality and quantity of evidence were available for assessing the accuracy of the different computer-assisted implant placement. The rapidly evolving field of digital dentistry and the new developments will further improve the accuracy of guided implant placement. In the interest of being able to draw dependable conclusions and for the further evaluation of the parameters used for accuracy measurements, randomized, controlled single or multi-centered clinical trials are necessary.

Periosteal microcirculatory reactions in a zoledronate-induced osteonecrosis model of the jaw in rats.

OBJECTIVES: Nitrogen-containing bisphosphonates induce osteonecrosis mostly in the jaw and less frequently in other bones. Because of the crucial role of periosteal perfusion in bone repair, we investigated zoledronate-induced microcirculatory reactions in the mandibular periosteum in comparison with those in the tibia in a clinically relevant model of bisphosphonate-induced medication-related osteonecrosis of the jaw (MRONJ). MATERIALS AND METHODS: Sprague-Dawley rats were treated with zoledronate (ZOL; 80 i.v. µg/kg/week over 8 weeks) or saline vehicle. The first two right mandibular molar teeth were extracted after 3 weeks. Various systemic and local (periosteal) microcirculatory inflammatory parameters were examined by intravital videomicroscopy after 9 weeks. RESULTS: Gingival healing disorders (∼100%) and MRONJ developed in 70% of ZOL-treated cases but not after saline (shown by micro-CT). ZOL induced significantly higher degrees of periosteal leukocyte rolling and adhesion in the mandibular postcapillary venules (at both extraction and intact sites) than at the tibia. Leukocyte NADPH-oxidase activity was reduced; leukocyte CD11b and plasma TNF-alpha levels were unchanged. CONCLUSION: Chronic ZOL treatment causes a distinct microcirculatory inflammatory reaction in the mandibular periosteum but not in the tibia. The local reaction in the absence of augmented systemic leukocyte inflammatory activity suggests that topically different, endothelium-specific changes may play a critical role in the pathogenesis of MRONJ. CLINICAL RELEVANCE: This model permits for the first time to explore the microvascular processes in the mandibular periosteum after chronic ZOL treatment. This approach may contribute to a better understanding of the pathomechanism and the development of strategies to counteract bisphosphonate-induced side effects.

[Surgery on virtual model and 3-dimensional printing of a surgical wafer for the correction of a severe mandibular asymmetry]. / Virtuális modell-mutét és az okklúziós lemez háromdimenziós nyomtatása súlyos mandibula aszimmetria esetében.

Correction of a severe facial asymmetry presents a challenge due to the geometric complexity of the dentition, the bony structures and the soft tissues. In most asymmetric cases two-jaw surgery is recommended. Manual model surgery is an essential part of treatment planning but it can be complicated, time-consuming and may contain potential errors. We present a case of a 26-year-old male with a severe right-sided hemimandibular elongation when computerized simulation surgery was performed instead of manual model surgery. High-resolution computer tomography scan was done following presurgical orthodontics and the stack images were reformatted into a three-dimensional structure. The symmetry of the maxilla was corrected via a virtual Le Fort I osteotomy with the help of a three-dimensional planning software. A virtual intermediate surgical wafer was designed and fabricated with a three-dimensional printer. Virtual bilateral sagittal split osteotomy was performed and the mandible was rotated into the correct position to visualize the movements of the osteotomized segments. Real surgery was accomplished according to the virtual plan. The splint fitted well. There is a significant improvement in the facial symmetry; the occlusion is good and stable. This case supports the usage of computer-aided surgical planning and three-dimensional rapid prototyping for the correction of facial asymmetries.

A novel method for in vivo visualization of the microcirculation of the mandibular periosteum in rats.

OBJECTIVE: The periosteum plays an important role in bone physiology, but observation of its microcirculation is greatly limited by methodological constraints at certain anatomical locations. This study was conducted to develop a microsurgical procedure which provides access to the mandibular periosteum in rats. METHODS: Comparisons of the microcirculatory characteristics with those of the tibial periosteum were performed to confirm the functional integrity of the microvasculature. The mandibular periosteum was reached between the facial muscles and the anterior surface of the superficial masseter muscle at the external surface of the mandibular corpus; the tibial periosteum was prepared by dissecting the covering muscles at the anteromedial surface. Intravital fluorescence microscopy was used to assess the leukocyte-endothelial interactions and the RBCV in the tibial and mandibular periosteum. Both structures were also visualized through OPS and fluorescence CLSM. RESULTS: The microcirculatory variables in the mandibular periosteum proved similar to those in the tibia, indicating that no microcirculatory failure resulted from the exposure technique. CONCLUSION: This novel surgical approach provides simple access to the mandibular periosteum of the rat, offering an excellent opportunity for investigations of microcirculatory manifestations of dentoalveolar and maxillofacial diseases.

[Current approaches for early detection and treatment of medication-related osteonecrosis of jaw]. / Aktuális trendek a gyógyszer indukálta állcsontnecrosis korai felismerése és kezelési stratégiája terén.

Owing to the increased life expectancy, the incidence of rheumatoid disorders and oncologic cases with bone metastasis has dramatically increased. Despite the beneficial effects of the applied antiresorptive and antiangiogenic drugs (e.g. bisphosphonates), serious side effects such as jaw osteonecrosis may also develop. The aim of the authors was to summarize present knowledge about the possibilities of prevention and treatment in medication-related osteonecrosis of the jaw. Based on literature data, currently used detection methods for medication-related osteonecrosis of the jaw (including their advantages and limitations) are summarized. In addition, novel trends of surgical and adjuvant therapeutic approaches are also reviewed. The authors conclude that possibilities of prevention and efficacy of therapeutic interventions in this disorder are still limited possibly due to an incomplete knowledge of the underlying pathomechanism. An interdisciplinary cooperation for prevention and attentive monitoring in order to decrease the incidence of iatrogenic oral and maxillofacial complications seems to be particularly important.

[Knowledge of the management of dental trauma in southern Hungary]. / Traumás fogsérülések ellátásával kapcsolatos ismeretek vizsgálata Dél-Magyarországon.

The aim of the study was to evaluate the knowledge of dental trauma management in the southern part of Hungary among parents, teachers, medical doctors and dentists. A cross-sectional study was performed among the mentioned groups, with a structured questionnaire. The participants consisted of 275 people, most of them were parents (185), the other groups were smaller (30-30). 73.62% of parents recognised that the maxillary incisor of a 9-year-old girl is probably a permanent tooth. In case of the coronal fracture of this tooth 65.03% responded correctly. The correct response rate for the management of an avulsed tooth was only 39.26%, but in case of loss of consciousness 92.64% would act correctly. The Chi-square test indicated that there was a significant association between the correct recognition of the type of incisor and higher education (p < 0.01), and the number of seen TDIs. The 76.7% of the parents was not satisfied with his knowledge about TDLs, and 74.9% was interested in more information. In our study the parents performed generally better compared to other studies, but compared to the other three groups their results were worse. The knowledge of the teachers and the doctors was almost equivalent. The dentist had the best results. The level of knowledge of dental trauma management was inadequate among parents, but the teachers and doctors should improve their knowledge too. We suggest that it's necessary to start educational campaigns among groups that could be the primary caregivers of traumatic dental injuries.

Assessment of a novel electrochemically deposited smart bioactive trabecular coating (SBTC®): a randomized controlled clinical trial.

OBJECTIVES: A randomized controlled clinical trial of dental implants was conducted to compare the clinical properties of a novel electrochemically deposited calcium phosphate coating to those of a common marketed surface treatment. MATERIAL AND METHODS: Forty implants of the same brand and type were placed in 20 fully edentulous participants requiring mandibular implantation. The two study groups were defined by the surface treatment of the implants. 20 implants in the control group were coated via a commercial electrochemical surface treatment that forms a mixture of brushite and hydroxyapatite, while the remaining 20 in the test group were coated with a novel electrochemical Smart Bioactive Trabecular Coating (SBTC®). A split-mouth design was employed, with each participants receiving one control implant in one mandibular side and a test implant in the other. To mitigate potential operator-handedness bias, control and test implants were randomly assigned to mandibular sides. All cases underwent digital planning, implant placement with a static surgical guide, and participants received locator-anchored full-arch dentures. The primary outcome was implant stability (measured using Osstell ISQ) assessed at insertion, loading, and then 3 months, 9 months, and 2 years post-insertion. The secondary outcome was bone level change (in millimeters) over the 2-year observation period. Oral health-related quality of life (OHRQL) was monitored using the OHIP-14 questionnaire. Complications and adverse events were recorded. RESULTS: Successful osseointegration and implant stability were achieved in all cases, allowing loading. ISQ values steadily increased throughout the observation period. While no significant differences were observed between the SBTC® and control coatings, the test group exhibited a higher ISQ gain. Bone resorption was somewhat lower in the SBTC® but not significantly so. Patients' OHRQL significantly improved after denture delivery and remained stable throughout the follow-up. No complications or adverse events were observed. CONCLUSIONS: Based on the study results, we conclude that the new surface treatment is a safe alternative to the widely used control surface, demonstrating similar osseointegrative properties and time-dependent bone level changes. Further research may explore the broader implications of these findings. TRIAL REGISTRATION: The study is registered on clinicaltrials.gov under the identifier ID: NCT06034171.

A novel approach for determining instantaneous centers of rotation of the mandible with an intraoral scanner: A preliminary study.

OBJECTIVES: Recording and reproducing mandibular movements have been of key importance in the practice of dentistry for over a century. Recently, it has become possible to use digital technologies for these tasks. This study presents a preliminary method to try to identify the mandibular instantaneous centres of rotation based solely on intraoral scanners. METHODS: The dentitions of four participants were scanned, multiple inter-occlusal registrations and buccal scans were performed in closed and opened positions. Blender software was used to align the meshes during the post-scan digital workflow. Bite alignment accuracy was assessed and then improved with a strict exclusion protocol. An automated algorithm was used to find rotations between closed stage and open stage meshes. RESULTS: Our exclusion protocol reduced the bite alignment error significantly (p = 0.001) and the root-mean-square error value of the meshes decreased from 0.09 mm (SD = 0.15) to 0.03 mm (SD = 0.017). However, the remaining translational error caused an unexpectedly large shift in the axis of rotation (mean = 1.35 mm, SD = 0.77) with a 41.83: 1 ratio. As found in other studies, our results showed even a small amount of error during registration can shift the axis of rotation a large amount. This phenomenon will compromise the results of common pantographic methods which assume a rotation axis of the condyle. It also adds valuable information to the concept of instantaneous centers of rotation by revealing their true characteristics.

Current approaches to the diagnosis and management of odontogenic abscesses / Odontogén tályogok diagnosztikája és kezelése a nemzetközi ajánlások tükrében

A wide scale of medical professionals including general practitioners, dentists, maxillofacial surgeons, otolaryngologists or even emergency physicians frequently encounter patients suffering from abscesses of odontogenic origin. These dental infections spreading along the fascial planes into the adjacent anatomical spaces or by the lymphatic vessels and veins may result in life-threatening situations. It is essential to prevent and - in the case of an evolved disease pattern - to treat them properly, since improper or delayed treatment may entail avoidable burdens on the healthcare system. Our aim was to review the current literature regarding the development, diagnostics and treatment of odontogenic infections. A review of the English and Hungarian literature was performed. Considerations regarding the surgical management of dental abscesses have well-tried, traditional routes. Prompt intervention is considered mandatory with surgical decompression of the swelling by performing incision and drainage. A rapid improvement of radiology has provided the possibility to realize and avoid fatal consequences of this disorder. The administration route, necessity and duration of empiric antibiotic therapy are still debated, protocols vary across studies. Based on inconsistency in findings among the studies and lack of high-quality prospective studies, future research should evaluate evidence-based and effective management of dental abscesses.

Augmentation of the vertical bone defects of the mandible and maxilla with autogenous bone block / A mandibula és a maxilla vertikális csonthiányainak autológ csontblokkal végzett augmentációja. Utánkövetéses retrospektív tanulmány

Introduction: Vertical augmentation of the alveolar process for dental implantation is a well-established approach. The literature suggests that vertical ridge augmentation is associated with an elevated risk of complications and bone resorption compared to lateral bone augmentation or sinus elevation. Objective: We sought to retrospectively analyze the long-term success of vertical augmentation in terms of bone stability and complications. Method: We reviewed the medical records of 186 patients who underwent monocortical bone augmentation and nar-rowed them down to two smaller groups. Patients in one group were treated by sinus elevation, while patients in the other group were treated by vertical ridge augmentation. In both groups, the treatment was carried out utilizing autogenous monocortical bone blocks. Only those files were selected for analysis where follow-up documentation of a minimum of 3 years with panoramic X-ray images was available. We analyzed the frequency and degree of bone resorption and the frequency of implant loss and complications. Results: 72% of the augmentation cases and 92% of the implants in the sinus elevation group were free of bone resorp-tion in contrast to the vertical ridge augmentation group where only 46% of the augmentation cases and 24% of the implants were free of bone resorption. No implant loss or peri-implant complications were observed in either group. Conclusion: The results support the literature in that the risk of bone resorption is higher in cases of vertical ridge augmentation. However, this was not accompanied by functional alterations, peri-implant complications, or inflam-matory phenomena and neither did it lead to implant loss, even in cases with more than a decade of follow-up.

Esthetic and functional reconstruction of large mandibular defects using free fibula flap and implant-retained prosthetics - a case series with long-term follow-up.

BACKGROUND: The reconstructive and rehabilitative management of large mandibular defects with basal continuity is challenging in many respects, especially in the vertical dimension. The free fibula flap is an under-utilised but efficient approach in this indication. The aim of this case series is to demonstrate its use and long-term success. CASE PRESENTATION: Three cases are presented, where the patient had a large bone defect (at least 5 cm in length and 1 cm in the vertical dimension), but the continuity of the mandible was maintained. Two cases were related to pathological fracture and one was a large defect due to oncological surgery. Vertical augmentation with free microvascularised fibula flap was carried out, followed by implant-retained prosthetic therapy. Clinical status has been followed up for 5 to 6 years, with special attention to the condition of the peri-implant tissues and any radiographically detectable alterations or complications. No complications occurred during the follow-up. Function and esthetics have remained unchanged throughout. CONCLUSIONS: Free microvascularised fibula flap reconstruction combined with implant-retained prosthetics allows a lasting functional and esthetic solution in the discussed indication.

Vertical mandibular bone augmentation by the osteodistraction of the transplanted fibula free flap: A case series with long-term follow-up.

Vertical augmentation of the mandible to prepare dental implant therapy is still a challenge, especially with large mandible defects. Reconstruction with fibula free flap is a regularly applied approach in such cases, but it does not always yield optimal results: the resulting crestal height might differ significantly from the crestal height of the patient's intact bone, which makes esthetic and functional rehabilitation difficult. Osteodistraction of the integrated flap is a known but rarely discussed approach where the already integrated flap undergoes additional distraction. Through the four cases reported here, we would like to demonstrate that the osteodistraction of the transplanted fibula free flap is a useful and efficient method of secondary augmentation for cases where the flap itself fails to produce the desired crestal height, and no other method is applicable. The cases show that the method allows outcomes that are highly satisfactory, both in the functional and esthetic sense.

Evaluation of the Soft Tissue Changes after Rapid Maxillary Expansion Using a Handheld Three-Dimensional Scanner: A Prospective Study.

Facial soft tissue esthetics is a priority in orthodontic treatment, and emerging of the digital technologies can offer new methods to help the orthodontist toward an esthetic outcome. This prospective study aimed to assess the soft tissue changes of the face after six months of retention following Rapid Maxillary Expansion (RME). The sample consisted of 25 patients (13 females, 12 males, mean age: 11.6 years) who presented with unilateral or bilateral posterior crossbite requiring RME, which was performed with a Hyrax expander. 3D facial images were obtained before treatment (T0) and at the end of a six-month retention period after the treatment (T1) using a structured-light 3D handheld scanner. Linear and angular measurements were performed and 3D deviation analyses were done for six morphological regions of the face. Significant changes in various areas of the nasal and the upper lip regions were observed. Based on the results of the study and within the limitations of the study, RME with a Hyrax expander results in significant morphological changes of the face after a six-month retention period.

Patterns of Facial Profile Preference in a Large Sample of Dental Students: A Cross-Sectional Study.

The objective of this study was to explore dental students' facial profile preferences in a large sample of students. Nine hundred and nineteen dental students of four dental schools were involved. As part of a larger study on dentofacial esthetics, six photo series consisting of one unaltered and four altered variants of the same female profile were distributed among the students. The altered features were ones that are esthetically significant according to the literature. The students had to indicate the photo in each series that they preferred. The data were analyzed in a regression model in which preference in the given photo series was the dependent variable and gender, grade of studies, and dental school were the factors. Eight hundred and sixty-one students (93.7%) responded. Gender and dental school were not associated with the observed preferences, but the grade of studies was associated for three of the modified parameters: chin prominence, the sagittal position of the maxillary dental arch, and the simultaneous modification of the prominence of the chin and the nose. This study has confirmed several earlier observations, and new observations have also been made. We have demonstrated that the anteroposterior position of the maxillary incisors may be an important determinant of profile esthetics, even if this position does not influence the situation of the soft tissues and if the forehead cannot be used as a reference. We have also shown that the harmony between the nose and the chin overrides the importance of their individual dimensions.