Professional consensus on orthodontic risks: What orthodontists should tell their patients.

INTRODUCTION: Effective communication of risk is a requisite for valid consent, shared decision-making, and the provision of person-centered care. No agreed standard for the content of discussions with patients about the risks of orthodontic treatment exists. This study aimed to produce a professional consensus recommendation about the risks that should be discussed with patients as part of consent for orthodontic treatment. METHODS: A serial cross-sectional survey design using a modified electronic Delphi technique was used. Two survey rounds were conducted nationally in the United Kingdom using a custom-made online system. The risks used as the prespecified items scored in the Delphi exercise were identified through a structured literature review. Orthodontists scored treatment risks on a 1-9 scale (1 = not important, 9 = critical to discuss with patients). The consensus that a risk should be discussed as part of consent was predefined as ≥70% orthodontists scoring risk as 7-9 and <15% scoring 1-3. RESULTS: The electronic Delphi was completed by 237 orthodontists who reached a professional consensus that 10 risks should be discussed as part of consent for orthodontic treatment; demineralization, relapse, resorption, pain, gingivitis, ulceration, appliances breaking, failed tooth movements, treatment duration, and consequences of no treatment. CONCLUSIONS: A professional orthodontic consensus has been reached that 10 key risks should be discussed with patients as part of consent for orthodontic treatment. The information in this evidence base should be tailored to patients' individual needs and delivered as part of a continuing risk communication process.

Factors influencing orthodontic treatment outcome in South East Wales and implications for service commissioning.

AIM: To determine factors that may influence the outcome of orthodontic treatment undertaken in General Dental Services/Personal Dental Services in South East Wales. DESIGN AND SETTING: A retrospective study of a requested 20 consecutively treated cases (for the year 2014-2015) provided by 26 performers in South East Wales. METHOD: Performer and patient information was obtained by use of a questionnaire and FP17OW forms, respectively. A calibrated investigator recorded the Index of Orthodontic Treatment Need (IOTN), Peer Assessment Rating (PAR) and the Index of Complexity, Outcome and Need (ICON) on start- and end-study models for each case. Descriptive and regression analyses were undertaken to identify any predictive factors of a good treatment outcome. RESULTS: Two respondents completed < 20 cases, so all of their cases were assessed. A total of 495 cases were assessed. The overall achieved mean end-PAR score of 5 is collectively a good occlusal outcome. Predictive factors of a good quality of occlusal outcome (end-PAR score being ⩽ 5) were: dual arch treatment; use of functional with fixed appliances; treatment undertaken in non-corporate practices; and treatment undertaken by registered specialists (P < 0.001). Predictive factors for occlusal improvement (change in PAR score) were: IOTN aesthetic component (AC); IOTN dental health component (DHC) (1-3 or 4-5); and number of arches treated and malocclusion type (P < 0.001). CONCLUSIONS: Dual arch fixed appliances undertaken by orthodontic specialists in non-corporate environments produced the highest quality orthodontic outcomes. Those who have the highest need for treatment according to IOTN DHC and AC benefit most in terms of improvement achieved in PAR score.

Effectiveness of an audience response system on orthodontic knowledge retention of undergraduate dental students--a randomised control trial.

OBJECTIVE: To determine the effect of an audience response system (ARS) on knowledge retention of dental students and to gauge student perceptions of using the ARS. DESIGN: Randomised control study. SETTING: School of Dentistry, Cardiff University. PARTICIPANTS: Seventy four second-year dental students were stratified by gender and randomised anonymously to one of two groups. METHODS: One group received a lecture on orthodontic terminology and diagnosis in a traditional didactic format and the other received the same lecture integrated with ARS slides. Students completed an assessment of multiple-choice questions (MCQs) scored out of 20, before and immediately after the lecture. Students were also asked to complete a self-reported questionnaire on their perceptions of ARS. RESULTS: Both groups had statistically significant increases in MCQ scores post-lecture (ARS mean increase 3.6 SD2.0, 95% CI 2.2-3.5 and Didactic mean increase 2.9 SD2.3, 95% CI 2.8-4.3). A mixed-design analysis of variance showed that ARS led to an improved MCQ score (by 0.8 or 25%) compared to the didactic group, although this effect was not significant (P = 0.15). The effect of gender at baseline (P = 0.49), post-lecture (P = 0.73) and increase in MCQ score split by group (P = 0.46) was also not significant. Students reported that the ARS was easy to use, helped them engage with the lecture and encouraged them to work harder. CONCLUSION: The ARS did not lead to a significant increase in short-term orthodontic knowledge recall of students compared with didactic teaching. However, the use of ARS within orthodontic teaching could make lectures more interactive and engaging.

The influence of asthma on face shape: a three-dimensional study.

Respiratory activity may have an influence on craniofacial development and interact with genetic and environmental factors. It has been suggested that certain medical conditions such as asthma have an influence on face shape. The aim of the study is to investigate whether facial shape is different in individuals diagnosed as having asthma compared with controls. Study design included observational longitudinal cohort study. Asthma was defined as reported wheezing diagnosed at age 7 years and 6 months. The cohort was followed to 15 years of age as part of the Avon Longitudinal Study of Parents and Children. A total of 418 asthmatics and 3010 controls were identified. Three-dimensional laser surface facial scans were obtained. Twenty-one reproducible facial landmarks (x, y, z co-ordinates) were identified. Average facial shells were created for asthmatic and non-asthmatic males and females to explore surface differences. The inter-ala distance was 0.4mm wider (95% CI) and mid-face height was 0.4mm (95% CI) shorter in asthmatic females when compared with non-asthmatic females. No facial differences were detected in male subjects. Small but statistically significant differences were detected in mid-face height and inter-ala width between asthmatic and non-asthmatic females. No differences were detected in males. The lack of detection of any facial differences in males may be explained by significant facial variation as a result of achieving different stages of facial growth due to pubertal changes, which may mask any underlying condition effect.

A three-dimensional analysis of the effect of atopy on face shape.

Three-dimensional (3D) imaging technology has been widely used to analyse facial morphology and has revealed an influence of some medical conditions on craniofacial growth and morphology. The aim of the study is to investigate whether craniofacial morphology is different in atopic Caucasian children compared with controls. Study design included observational longitudinal cohort study. Atopy was diagnosed via skin-prick tests performed at 7.5 years of age. The cohort was followed to 15 years of age as part of the Avon Longitudinal Study of Parents and Children (ALSPAC). A total of 734 atopic and 2829 controls were identified. 3D laser surface facial scans were obtained at 15 years of age. Twenty-one reproducible facial landmarks (x, y, z co-ordinates) were identified on each facial scan. Inter-landmark distances and average facial shells for atopic and non-atopic children were compared with explore differences in face shape between the groups. Both total anterior face height (pg-g, pg-men) and mid-face height (Is-men, sn-men, n-sn) were longer (0.6 and 0.4mm respectively) in atopic children when compared with non-atopic children. No facial differences were detected in the transverse and antero-posterior relationships. Small but statistically significant differences were detected in the total and mid-face height between atopic and non-atopic children. No differences were detected in the transverse and antero-posterior relationships.

New developments in: three-dimensional planning for orthognathic surgery.

The limitations of plain film radiographs are well documented and the recent introduction of cone beam computed tomography (CBCT) imaging has been a breakthrough in enabling three-dimensional (3D) visualization of the bony skeleton and dentition. There are many reported applications for CBCT in the field of orthodontics and maxillofacial surgery, including the localization of impacted teeth and implant site assessment. More recently, by augmenting CBCT volumes of the maxilla, mandible and dentition, a virtual 3D patient can be created, which can allow planning of orthognathic surgery entirely in 3D. A commercially available software package for 3D orthognathic planning (Maxilim(R), Medicim NV, Belgium) is independently reviewed, familiarizing the reader with the technique for creating a virtual 3D patient, outlining the advantages and disadvantages of the software and concluding on the feasibility of its routine use in clinical practice.

Removable rapid maxillary expansion.

A novel removable rapid maxillary expansion appliance is described for use in routine clinical practice. The laboratory construction and clinical technique is described, and the advantages of the appliance over conventional rapid expansion devices are highlighted.

Adolescent perceptions of orthodontic treatment risks and risk information: A qualitative study.

INTRODUCTION: For effective risk communication, clinicians must understand patients' values and beliefs in relation to the risks of treatment. This qualitative study aimed to explore adolescent perceptions of orthodontic treatment risks and risk information. METHODS: Five focus groups were carried out with 32 school/college pupils aged 12-18 in Wales, UK. Participants were purposively selected and had all experienced orthodontic treatment. A thematic approach was used for analysis and data collection was completed at the point of data saturation. RESULTS: Four themes emerged from the data; (a) day-to-day risks of orthodontic treatment, (b) important orthodontic risk information, (c) engaging with orthodontic risk information and (d) managing the risks of orthodontic treatment. Day-to-day risks of orthodontic treatment that were affecting participants "here and now" were of most concern. Information about preventing the risks of treatment was deemed to be important. Participants did not actively seek risk information but engaged passively with information from convenient sources. Perceptions of risk susceptibility influenced participants' management of the risks of orthodontic treatment. CONCLUSIONS: This study demonstrates that adolescent patients can understand information about the nature and severity of orthodontic treatment risks. However, adolescent patients can have false perceptions if the risks are unfamiliar, perceived only to have a future impact or if seen as easy to control. Adolescent patients must be provided with timely and easily accessible risk information and with practical solutions to prevent the risks of treatment. CLINICAL SIGNIFICANCE: The views and experiences gathered in this study can assist clinicians to better understand their young patients' beliefs about treatment risks, facilitate effective risk communication and contribute to improved patient-centred care.

Factors influencing patient-reported quality of life in pretreatment orthognathic surgery patients.

OBJECTIVE: To investigate the relationship between condition-specific quality of life (QoL) and occlusal/skeletal traits of pretreatment orthognathic surgery patients. MATERIALS AND METHODS: Patients referred for orthognathic surgery during the 2012-2014 period were asked to complete the Orthognathic Quality of Life Questionnaire (OQLQ) at consultation. Patient demographics, indices of treatment need, occlusal traits, and cephalometric variables were also recorded. Bivariate analyses were carried out between the OQLQ scores and the clinical measurements. Significant variables were added to a multivariate regression model to determine the effect of these predictive factors on OQLQ. RESULTS: One hundred and two patients were recruited. Initial analyses showed that gender and overjet were significantly associated with the overall OQLQ score. Being female increased the overall OQLQ score by 15.6 points when compared to males (95% confidence interval [CI], 7.4-23.8). Females also had significant associations in the social and awareness domains of the OQLQ. The magnitude of overjet away from normal values was associated with poorer overall QoL, with significant relationships in the esthetic and functional domains. The Index of Orthognathic Functional Treatment Need was significantly associated with the functional domain of OQLQ, with patients in category 5 scoring a mean of 10.0 points more than patients in category 4 (95% CI, 2.1-17.8). The Index of Complexity, Outcome and Need and other cephalometric variables were not associated with the OQLQ. CONCLUSIONS: Females are more aware of their facial deformity and report a greater social detriment when compared to males. Patients with a higher orthognathic treatment need report greater functional disadvantage.

The influence of snoring, mouth breathing and apnoea on facial morphology in late childhood: a three-dimensional study.

OBJECTIVE: To explore the relationship between the prevalence of sleep disordered breathing (SDB) and face shape morphology in a large cohort of 15-year-old children. DESIGN: Observational longitudinal cohort study SETTING: Avon Longitudinal Study of Parents and Children (ALSPAC), South West of England. PARTICIPANTS: Three-dimensional surface laser scans were taken for 4784 white British children from the ALSPAC during a follow-up clinic. A total of 1724 children with sleep disordered breathing (SDB) and 1862 healthy children were identified via parents' report of sleep disordered symptoms for their children. We excluded from the original cohort all children identified as having congenital abnormalities, diagnoses associated with poor growth and children with adenoidectomy and/or tonsillectomy. MAIN OUTCOME MEASURES: Parents in the ALSPAC reported sleep disordered symptoms (snoring, mouth breathing and apnoea) for their children at 6, 18, 30, 42, 57, 69 and 81 months. Average facial shells were created for children with and without SDB in order to explore surface differences. RESULTS: Differences in facial measurements were found between the children with and without SDB throughout early childhood. The mean differences included an increase in face height in SDB children of 0.3 mm (95% CI -0.52 to -0.05); a decrease in mandibular prominence of 0.9° (95% CI -1.30 to -0.42) in SDB children; and a decrease in nose prominence and width of 0.12 mm (95% CI 0.00 to 0.24) and 0.72 mm (95% CI -0.10 to -0.25), respectively, in SDB children. The odds of children exhibiting symptoms of SDB increased significantly with respect to increased face height and mandible angle, but reduced with increased nose width and prominence. CONCLUSIONS: The combination of a long face, reduced nose prominence and width, and a retrognathic mandible may be diagnostic facial features of SBD that may warrant a referral to specialists for the evaluation of other clinical symptoms of SDB.

A clinical report of nonsyndromic concomitant hypo-hyperdontia.

Although hypodontia and supernumerary teeth are often considered as mutually exclusive conditions, this case report presents an unusual case of hypodontia and a supernumerary tooth occurring simultaneously. An adolescent male was referred to the local hospital department regarding upper arch crowding. Plain film radiographs confirmed the congenital absence of both lower lateral incisors in addition to an unerupted conical supernumerary tooth in the maxillary midline. This condition has been called hypo-hyperdontia and in this paper, we discuss the clinical findings and treatment planning considerations in relation to the limited number of previously reported cases. The case report raises awareness of concomitant hypo-hyperdontia and serves to highlight that concomitant anomalies should be excluded when hypodontia or supernumerary teeth are diagnosed.

The orthodontic and surgical management of Zimmerman-Laband syndrome.

Zimmermann-Laband syndrome (ZLS) is a rare autosomal disorder characterized by gingival fibromatosis, abnormalities of the nose and/or ears, hypoplasia of the nails or terminal phalanges of the hands and feet, hyperextensibility of joints, hepatosplenomegaly, hirsutism, and intellectual disability. The characteristics of the syndrome are highly variable and complicated. This paper reports a case of ZLS and the clinical manifestations encountered in relation to the current available literature. The comprehensive management of the patient's dentition is described, focusing on the orthodontic and surgical considerations clinicians should be aware of when treating patients with the syndrome.

Three-dimensional assessment of functional change following Class 3 orthognathic correction--a preliminary report.

Orthognathic surgery is a well-documented clinical procedure for patients who complain of functional and aesthetic problems related to dento-facial imbalance. The aims of treatment are to establish facial harmony, normalise function and maximise the stability of the outcome. Conventional diagnostic aids to treatment include plain film radiographs and photographs which provide a static analysis of the facial structures at a particular point in time. Functional assessment of facial movement is rarely performed but could have important implications on the stability of the surgery through post-surgical soft tissue adaptation to the new skeletal relationships. A case report is presented for which novel three-dimensional motion analysis techniques were used to assess facial movement through the surgical correction of a Class 3 malocclusion. It was found that facial movement increased for all circum-oral postures post-surgery. Future research in this field recommends collection of data from a control group to allow comparisons of facial movement between different surgical samples.

Facial movement in 3 dimensions: average templates of lip movement in adults.

OBJECTIVE: To construct 3-dimensional (3D) templates of average lip movement based on a group of normal healthy subjects. STUDY DESIGN: Cross-sectional study. SETTING: School of Dentistry, Cardiff University, United Kingdom. SUBJECTS AND METHODS: One hundred fifteen white subjects were asked to perform 2 reproducible verbal gestures (/puppy/ and /rope/) in a normal relaxed manner. The sequences were captured using a noninvasive, 3D motion scanner (3dMDFace Dynamic System). Mesh-registration software was used to align sequential facial shells to a standardized reference plane. Lip movement during the verbal facial gestures was quantified using the displacement vectors (x, y, z coordinates) of 6 lip landmarks of sequential 3D facial shells subtracted from the reference or rest shell. Descriptive statistics were used to build references for average lip movement, and independent t tests were used to compare lip movement between men and women. RESULTS: Mean reference movements were created for lip opening, lip stretch, and lip purse that corresponded to the visemes /pu/ /ppy/ and /rope/, respectively. There were statistically significant differences in the lip movement between genders for the visemes /pu/ and /ppy/, although when quantified these were found not to be of clinical significance. Men favored left-sided movement and women right-sided movement, although only slightly--again, when quantified, this was considered to be within symmetrical limits. CONCLUSION: It was possible to quantify and create normal templates of lip movement for the words /puppy/ and /rope/. Men and women show similar standardized lip movements for these 2 words.

A comparison of the reproducibility of verbal and nonverbal facial gestures using three-dimensional motion analysis.

OBJECTIVE: To evaluate the reproducibility of selected verbal and nonverbal facial gestures. STUDY DESIGN: Cross-sectional study. SETTING: School of Dentistry, Cardiff University, Cardiff, United Kingdom. SUBJECTS AND METHODS: Twenty-five white subjects were asked to perform four verbal gestures and two nonverbal facial gestures in a normal, relaxed manner. The sequences were captured using a noninvasive, three-dimensional motion analysis scanner (3dMDFace Dynamic System; 3Q Technologies, Atlanta, GA) at an initial time point (T1) and one month later (T2). Principal component analysis was used to analyze the dynamics of lip movement, and dynamic time warping was used to evaluate the reproducibility between T1 and T2 for the individual facial gestures. Statistical analyses were used to compare the reproducibility of the different facial gestures. RESULTS: All four verbal gestures were found to be significantly more reproducible than the nonverbal gestures. The word "puppy" was most reproducible, and the normal smile expression least reproducible. A hierarchy of reproducibility is proposed as "puppy," "baby," "rope," "bob," standardized smile, normal smile. CONCLUSION: Verbal facial gestures, in particular the words "puppy" and "baby," are more appropriate for use in the assessment of lip movement when compared with smile expressions because of their high level of reproducibility over a one-month period.