Camouflage Treatment for Skeletal Maxillary Protrusion and Lateral Deviation with Classic-Type Ehlers-Danlos Syndrome.

We herein report the case of a 19-year-old female with a transverse discrepancy, skeletal Class II malocclusion, severe crowding with concerns of classic-type Ehlers-Danlos syndrome (EDS), aesthetics problems and functional problems. The main characteristics of classic EDS are loose-jointedness and fragile, easily bruised skin that heals with peculiar "cigarette-paper" scars. The anteroposterior and transverse skeletal discrepancies can generally be resolved by maxilla repositioning and mandibular advancement surgery following pre-surgical orthodontic treatment. However, this patient was treated with orthodontic camouflage but not orthognathic surgery because of the risks of skin bruising, poor healing and a temporomandibular disorder. A satisfactory dental appearance and occlusion were achieved after camouflage treatment with orthodontic anchor screws and the use of Class II elastics, including the preservation of the stomatognathic functions. Acceptable occlusion and dentition were maintained after a two-year retention period. This treatment strategy of orthodontic camouflage using temporary anchorage, such as anchor screws and Class II elastics, may be a viable treatment option for skeletal malocclusion patients with EDS.

Comparative evaluation of treatment outcomes between temporary anchorage devices and Class III elastics in Class III malocclusions.

INTRODUCTION: Our objective was to elucidate the differences in treatment outcomes caused by the different mechanics of temporary anchorage devices (TADs) and Class III elastics in patients with Class III malocclusions. METHODS: Records of 23 patients with Angle Class III malocclusion were selected retrospectively. All had been treated with nonextraction comprehensive orthodontic treatment; 11 were treated with TADs and 12 with Class III elastics. Pretreatment and posttreatment lateral cephalograms were used for evaluation of the treatment outcomes. A paired t test and a Student t test were used for statistical analysis. RESULTS: In both groups, proper overjet and Class I molar relationships were achieved, and the occlusal plane was rotated counterclockwise. In the elastics group, distal tipping of the mandibular molars, extrusion of the mandibular incisors and maxillary molars, clockwise rotation of the mandibular plane angle, and increased ANB angle were observed. In the TADs group, distal tipping and intrusion of the mandibular molars, bodily movement of the mandibular incisors, and reduced mandibular plane angle were observed. CONCLUSIONS: In nonextraction treatment for Class III malocclusions, the mandibular plane angle was increased in the elastics group, whereas it was decreased in TADs group. Thus, we suggest that Class III elastics are preferred for low-angle, short-face patients, whereas TADs are preferred for high-angle, long-face patients.

A Single-center, Open-label, Randomized Controlled Clinical Trial to Evaluate the Efficacy and Safety of the Indirect Bonding Technique.

Although accurate bracket placement is essential for orthodontic treatment, many practitioners apply brackets indiscriminately with direct or indirect bonding techniques. Nonetheless, there have been few prospective clinical comparisons of the 2 techniques. We will therefore conduct a single-center, randomized control trial in 100 patients aged 12 years and diagnosed with malocclusion. All patients will receive orthodontic treatment using brackets with direct or indirect bonding techniques. The primary endpoints will be the total treatment time, occlusal index, discomfort at bonding, and oral hygiene after bonding. This study will clarify whether indirect bonding can improve the efficiency of orthodontic treatment.

Isolation and characterization of SSEA-4-positive subpopulation of human deciduous dental pulp cells.

OBJECTIVES: It is well accepted that stage-specific embryonic antigen (SSEA)-4 is an antigen that is useful to isolate adult stem cells analogous to embryonic stem cells. Therefore, in the present study, we investigated whether SSEA-4 can also be used as a marker to identify human deciduous dental pulp (D-DP) stem cells. MATERIALS AND METHODS: Intact deciduous teeth were collected from healthy patients who were undergoing orthodontic treatment at Okayama University Hospital. Immunofluorescence analysis, flow cytometric analysis, and multilineage differentiation assay were performed to characterize SSEA-4+ D-DP cells. RESULTS: The D-DP cells had the characteristics of mesenchymal stem cells (MSCs), namely plastic adherence, specific surface antigen expression, and multipotent differentiation potential. SSEA-4 expression was detected in D-DP cells in vitro and ex vivo samples. A flow cytometric analysis demonstrated that 21.2 % of the D-DP cells were positive for SSEA-4. The SSEA-4+ clonal D-DP cells showed multilineage differentiation potential toward adipocytes, osteoblasts, and chondrocytes in vitro. In fact, 26.1 % (6/23) of the SSEA-4+ clonal D-DP cells showed adipogenic potential, 91.3 % (21/23) showed osteogenic potential, 91.3 % (21/23) showed chondrogenic potential, and 87.0 % (20/23) showed both osteogenic and chondrogenic potential. CONCLUSIONS: Thus, the majority of SSEA-4+ D-DP cells had the potential for multilineage differentiation. Hence, SSEA-4 appears to be a specific marker that can be used to identify D-DP stem cells. CLINICAL RELEVANCE: SSEA-4+ D-DP cells appear to be a promising source of stem cells for regenerative therapy.

Class II malocclusion with complex problems treated with a novel combination of lingual orthodontic appliances and lingual arches.

This case report describes a novel method of combining lingual appliances and lingual arches to control horizontal problems. The patient, who was 25 years of age at her first visit to our hospital with a chief complaint of crooked anterior teeth, was diagnosed with skeletal Class II and Angle Class II malocclusion with anterior deep bite, lateral open bite, premolar crossbite, and severe crowding in both arches. She was treated with premolar extractions and temporary anchorage devices. Conventionally, it is ideal to use labial brackets simultaneously with appliances, such as a lingual arch, a quad-helix, or a rapid expansion appliance, in patients with complex problems requiring horizontal, anteroposterior, and vertical control; however, this patient strongly requested orthodontic treatment with lingual appliances. A limitation of lingual appliances is that they cannot be used with other conventional appliances. In this report, we present the successful orthodontic treatment of a complex problem using modified lingual appliances that enabled combined use of a conventional lingual arch.

Roles of heparan sulfate sulfation in dentinogenesis.

Cell surface heparan sulfate (HS) is an essential regulator of cell signaling and development. HS traps signaling molecules, like Wnt in the glycosaminoglycan side chains of HS proteoglycans (HSPGs), and regulates their functions. Endosulfatases Sulf1 and Sulf2 are secreted at the cell surface to selectively remove 6-O-sulfate groups from HSPGs, thereby modifying the affinity of cell surface HSPGs for its ligands. This study provides molecular evidence for the functional roles of HSPG sulfation and desulfation in dentinogenesis. We show that odontogenic cells are highly sulfated on the cell surface and become desulfated during their differentiation to odontoblasts, which produce tooth dentin. Sulf1/Sulf2 double null mutant mice exhibit a thin dentin matrix and short roots combined with reduced expression of dentin sialophosphoprotein (Dspp) mRNA, encoding a dentin-specific extracellular matrix precursor protein, whereas single Sulf mutants do not show such defective phenotypes. In odontoblast cell lines, Dspp mRNA expression is potentiated by the activation of the Wnt canonical signaling pathway. In addition, pharmacological interference with HS sulfation promotes Dspp mRNA expression through activation of Wnt signaling. On the contrary, the silencing of Sulf suppresses the Wnt signaling pathway and subsequently Dspp mRNA expression. We also show that Wnt10a protein binds to cell surface HSPGs in odontoblasts, and interference with HS sulfation decreases the binding affinity of Wnt10a for HSPGs, which facilitates the binding of Wnt10a to its receptor and potentiates the Wnt signaling pathway, thereby up-regulating Dspp mRNA expression. These results demonstrate that Sulf-mediated desulfation of cellular HSPGs is an important modification that is critical for the activation of the Wnt signaling in odontoblasts and for production of the dentin matrix.

Stage-specific embryonic antigen-4 identifies human dental pulp stem cells.

Embryonic stem cell-associated antigens are expressed in a variety of adult stem cells as well as embryonic stem cells. In the present study, we investigated whether stage-specific embryonic antigen (SSEA)-4 can be used to isolate dental pulp (DP) stem cells. DP cells showed plastic adherence, specific surface antigen expression, and multipotent differentiation potential, similar to mesenchymal stem cells (MSC). SSEA-4+ cells were found in cultured DP cells in vitro as well as in DP tissue in vivo. Flow cytometric analysis demonstrated that 45.5% of the DP cells were SSEA-4+. When the DP cells were cultured in the presence of all-trans-retinoic acid, marked downregulation of SSEA-3 and SSEA-4 and the upregulation of SSEA-1 were observed. SSEA-4+ DP cells showed a greater telomere length and a higher growth rate compared to ungated and SSEA-4- cells. A clonal assay demonstrated that 65.5% of the SSEA-4+ DP cells had osteogenic potential, and the SSEA-4+ clonal DP cells showed multilineage differentiation potential toward osteoblasts, chondrocytes, and neurons in vitro. In addition, the SSEA-4+ DP cells had the capacity to form ectopic bone in vivo. Thus, our results suggest that SSEA-4 is a specific cell surface antigen that can be used to identify DP stem cells.

Relationship between orthodontic expertise and perception of need for orthodontic treatment for mandibular protrusion in Japan.

The aims of this study were to investigate how the Peer Assessment Rating (PAR index) predicts the perceived need for orthodontic treatment of mandibular protrusion in Japanese subjects, and to elucidate whether the perceived need for treatment was affected by the raters' orthodontic expertise. The subjects were 110 dental students and 32 orthodontists. We showed them casts of 10 untreated mandibular protrusion cases and gave them a questionnaire in which they had to describe their perceptions of the orthodontic treatment needs using a 10-point visual analog scale (VAS). The PAR index was used for cast evaluation. The PAR index scores showed significant correlations with the VAS scores. In casts with a low PAR score, there were no differences in the VAS scores between orthodontists and students. In casts with a PAR score greater than 23, the orthodontists perceived a significantly greater treatment need than did the students;for scores of 22, 28, and 29, students who had received orthodontic treatment themselves were more likely to perceive the treatment need. The PAR index is a good clinical predictor for assessing the perceived treatment needs for mandibular protrusion. Perception of the need for orthodontic treatment for mandibular protrusion depended on the degree of orthodontic expertise in Japanese subjects.

The influence of craniofacial morphology on mandibular border movements.

Although they are widely used as diagnostic signs of temporomandibular disorders, mandibular border movements reflect not only condylar movement, but also other factors. In the present study, the authors investigated the effect of craniofacial morphology on three different mandibular border movements: maximum jaw opening, maximum jaw protrusion, and maximum jaw laterotrusion. One hundred female subjects were selected from outpatients visiting the orthodontic clinic of Okayama University Hospital. The mandibular border movements were measured using an optical recording system in three dimensions as six degrees of freedom. The craniofacial morphology was evaluated using lateral cephalograms. The results suggest that craniofacial morphology had different influences on each mandibular border movement. In particular, during maximum jaw laterotrusion, lower incisor movement strongly reflected condylar movement, and the influence of craniofacial morphology on mandibular border movement was minimal. Therefore, lower incisor movement during maximum jaw laterotrusion appears suitable to evaluate condylar movement.

Core binding factor beta functions in the maintenance of stem cells and orchestrates continuous proliferation and differentiation in mouse incisors.

Rodent incisors grow continuously throughout life, and epithelial progenitor cells are supplied from stem cells in the cervical loop. We report that epithelial Runx genes are involved in the maintenance of epithelial stem cells and their subsequent continuous differentiation and therefore growth of the incisors. Core binding factor ß (Cbfb) acts as a binding partner for all Runx proteins, and targeted inactivation of this molecule abrogates the activity of all Runx complexes. Mice deficient in epithelial Cbfb produce short incisors and display marked underdevelopment of the cervical loop and suppressed epithelial Fgf9 expression and mesenchymal Fgf3 and Fgf10 expression in the cervical loop. In culture, FGF9 protein rescues these phenotypes. These findings indicate that epithelial Runx functions to maintain epithelial stem cells and that Fgf9 may be a target gene of Runx signaling. Cbfb mutants also lack enamel formation and display downregulated Shh mRNA expression in cells differentiating into ameloblasts. Furthermore, Fgf9 deficiency results in a proximal shift of the Shh expressing cell population and ectopic FGF9 protein suppresses Shh expression. These findings indicate that Shh as well as Fgf9 expression is maintained by Runx/Cbfb but that Fgf9 antagonizes Shh expression. The present results provide the first genetic evidence that Runx/Cbfb genes function in the maintenance of stem cells in developing incisors by activating Fgf signaling loops between the epithelium and mesenchyme. In addition, Runx genes also orchestrate continuous proliferation and differentiation by maintaining the expression of Fgf9 and Shh mRNA.

Intraoral vertical ramus osteotomy improved the stomatognathic function in an elderly patient with mandibular protrusion: a case report.

This article reports the successful surgical-orthodontic treatment of an elderly patient with dentofacial deformity and signs and symptoms of temporomandibular disorder (TMD). The patient was a 63-year-old woman with a concave profile due to mandibular protrusion. To correct skeletal deformities, the mandible was posteriorly repositioned by employing intraoral vertical ramus osteotomy (IVRO) following presurgical orthodontic treatment. After active treatment for 31 months, the facial profile was significantly improved and satisfactory occlusion was achieved. In addition, TMD symptoms of clicking sounds on the left side and difficulty in mouth opening were resolved. Regarding the findings of magnetic resonance imaging, anterior disc displacement in the opening phase was improved in the temporomandibular joint on the left side. Furthermore, stomatognathic functions were also improved without any aggravation of age-related problems. In conclusion, surgical repositioning of the mandible using IVRO leads to both morphological and functional improvements even in elderly patients.

Nonsurgical orthodontic treatment of a hypodivergent adult patient with bilateral posterior scissors bite and excessive overjet.

This report illustrates successful nonsurgical orthodontic treatment of a hypodivergent adult patient with bilateral posterior scissors bite (Brodie bite) and excessive overjet. A 26-year-old woman primarily reported maxillary incisor protrusion. She was diagnosed with Class ll division 1 malocclusion with skeletal Class I, short face, low mandibular plane angle and bilateral posterior scissors bite. A lingual arch with anterior bite block and posterior miniscrews with preadjusted edgewise appliances were used to improve the bilateral scissors bite. After achieving molar occlusion, the maxillary first premolars were extracted, and six miniscrews were used to improve the anterior-posterior and vertical discrepancies. After active treatment for 56 months, the convex facial profile with excessively protruded lips was improved and good interdigitation with ideal incisor relationship was achieved. Additionally, the irregular movements of the incisal path and the bilateral condyles during lateral excursion were improved. At 13 months of retention, a satisfactory facial profile, occlusion, and jaw movements were maintained. The treatment results suggest that miniscrews and fixed bite blocks were effective and efficient to facilitate correction of the bilateral scissors bite, excessive overjet, and vertical relationship correction in this nonsurgical orthodontic treatment.

The different effects of intraoral vertical ramus osteotomy (IVRO) and sagittal split ramus osteotomy (SSRO) on mandibular border movement.

OBJECTIVES: This study investigated the different effects of intraoral vertical ramus osteotomy (IVRO) and sagittal split ramus osteotomy (SSRO) on mandibular border movement. METHODS: The participants included 22 patients receiving IVRO and 22 patients receiving SSRO who were treated at Okayama University Hospital. Their mandibular border movement was evaluated in three dimensions with 6° of freedom using an optical recording system. RESULTS: A strong correlation between condylar and lower incisor movement was observed during maximum jaw protrusion and laterotrusion. Significant improvements in condylar and lower incisor movement were detected after orthognathic surgery during maximum jaw protrusion and laterotrusion in the IVRO group and during maximum jaw protrusion in the SSRO group. DISCUSSION: IVRO likely achieves greater improvement in jaw movement than SSRO. Therefore, the application of IVRO could be considered in the treatment of patients with jaw deformities featuring temporomandibular joint problems.

Topical application of lithium chloride on the pulp induces dentin regeneration.

We herein describe a novel procedure for dentin regeneration that mimics the biological processes of tooth development in nature. The canonical Wnt signaling pathway is an important regulator of the Dentin sialophosphoprotein (Dspp) expression. Our approach mimics the biological processes underlying tooth development in nature and focuses on the activation of canonical Wnt signaling to trigger the natural process of dentinogenesis. The coronal portion of the dentin and the underlying pulp was removed from the first molars. We applied lithium chloride (LiCl), an activator of canonical Wnt signaling, on the amputated pulp surface to achieve transdifferentiation toward odontoblasts from the surrounding pulpal cells. MicroCT and microscopic analyses demonstrated that the topical application of LiCl induced dentin repair, including the formation of a complete dentin bridge. LiCl-induced dentin is a tubular dentin in which the pulp cells are not embedded within the matrix, as in primary dentin. In contrast, a dentin bridge was not induced in the control group treated with pulp capping with material carriers alone, although osteodentin without tubular formation was induced at a comparatively deeper position from the pulp exposure site. We also evaluated the influence of LiCl on differentiation toward odontoblasts in vitro. In the mDP odontoblast cell line, LiCl activated the mRNA expression of Dspp, Axin2 and Kallikrein 4 (Klk4) and downregulated the Osteopontin (Osp) expression. These results provide a scientific basis for the biomimetic regeneration of dentin using LiCl as a new capping material to activate dentine regeneration.