Quantitative investigation of the esthetic impact of lip prominence in relation to the esthetic line.

INTRODUCTION: The purpose of this quantitative investigation was to assess the influence of lip prominence in relation to the esthetic line (E-line) on perceived attractiveness and threshold values of desire for treatment. METHODS: The lip prominence of an idealized silhouette male white profile image was altered incrementally between -16 mm to 4 mm from the E-line. The images were rated on a Likert scale by pretreatment orthognathic patients (n = 75), laypeople (n = 75), and clinicians (n = 35). RESULTS: In terms of perceived attractiveness, lips to E-line distance within the ranges of -12 mm to -16 mm and 0-4 mm in relation to the E-line was associated with a reduction in median attractiveness scores to below 4 in the patient and clinician groups of observers; for the lay group, the corresponding ranges were -14 mm to -16 mm and 2-4 mm. Relative lip prominence appears to be viewed as more attractive than lip retrusion. Clinicians were generally least likely to suggest treatment for varying levels of bilabial position. For a number of the images, there was reasonable agreement among clinicians and laypeople regarding whether treatment is required. For the clinician group, the only categories for desire for treatment were at a lip to E-line distance within the ranges of -14 mm to -16 mm and 2-4 mm. CONCLUSIONS: It is recommended that the range of normal variability of the prominence of the lips and threshold values of the desire for treatment be considered in planning.

Root Pulp Visibility as a mandibular maturity marker at the 18-year threshold in the Maltese population.

INTRODUCTION: The determination of age of majority (the 18-year-old threshold) using the popular Demirjian tooth staging method is unreliable, so other maturity markers are required. This study examines whether the Root Pulp Visibility (RPV) of the mandibular third molar is a useful indicator of age. METHODS: One thousand six dental panoramic radiographs (DPTs) were examined and the left mandibular third molar assessed according to the RPV stages using the method of Olze et al. (Int J Legal Med 124:183-186, 2010) as modified by Lucas et al. (Forensic Sci Int 270:98-102, 2017). Six hundred sixty-two DPTs, 288 males and 374 females, satisfied the inclusion criteria. RESULTS: Individuals who had reached stages RPV-A and RPV-B were represented in a wide range of ages spanning the 18-year-old threshold. Individuals who had reached stages RPV-C and RPV-D were all above the 18-year-old threshold. It was not possible to analyse a large number of DPTs for various reasons. DISCUSSION: Individuals whose mandibular third molar exhibited stages RPV-C and RPV-D may be deemed to have reached the age of majority. These results are consistent with other published studies. Variation in the rate of development of the third molar limits the applicability of this method. CONCLUSIONS: RPV staging is an accurate method of determining the 18-year-old threshold. Substitute methods are required in a large number of cases.

The Opinion of Different Observer Groups About the Esthetic Impact and Need for Surgical Correction of Varying Submental Lengths.

PURPOSE: This study evaluated the opinion of different observer groups about the influence of the submental length on perceived attractiveness and when surgical correction was deemed necessary. MATERIALS AND METHODS: The submental length of an idealized silhouette of a white male profile was altered incrementally between 5 and 95 mm. Images were rated for attractiveness on a Likert scale by pretreatment orthognathic surgery patients (n = 75), laypersons (n = 75), and clinicians (maxillofacial surgeons and orthodontists) (n = 35). RESULTS: For perceived attractiveness, the ideal submental length was approximately 50 mm (range, 40 to 75 mm). A submental length shorter than or equal to 30 mm was deemed unattractive by all 3 groups. Overall, a submental length less than 40 mm generally was judged less attractive than a comparable increase in length. Clinicians were generally least likely to suggest surgery for varying submental lengths. For this group, the cutoff at which the majority suggested surgery was a submental length of 25 mm or less. For the patient and layperson groups, the corresponding cutoff values were a length shorter than or equal to 30 mm or equal to 95 mm. CONCLUSIONS: A submental length of approximately 50 mm (range, 40 to 75 mm) was viewed by most observers as attractive. At 30 mm or less, it was generally deemed progressively less attractive. Clinicians were less likely to suggest corrective surgery than were the patient and layperson groups. For comparative proportional relationships, the submental length should be between the lower lip-chin height and lower facial height, assuming an otherwise proportional facial profile.

Patients with cleft: Experiences, understanding and information provision during treatment.

OBJECTIVE: To explore the knowledge of late adolescent and adults affected with cleft lip and/or palate (CL/P) about their condition and their experiences with information about treatment options and outcomes within the cleft care pathway. SETTING AND SAMPLE POPULATION: Twenty-eight people with CL/P had recently finished or were about to finish their definitive orthodontic/orthognathic (OGN) treatment. Participants were purposively recruited from two cleft centres in the UK. MATERIALS AND METHODS: Qualitative, semi-structured interviews were conducted and all interviews were recorded and transcribed verbatim. Thematic analysis was undertaken using the framework method. RESULT: There are a broad range of interpretations and explanations for both the causes and implications of CL/P amongst those living with the condition. This resulted in confusion and left participants vulnerable to misinformation and unable to combat stigma. In addition, there was some confusion about the implication of different treatment options. Participants felt that they did not receive enough information about the nature of the treatment that they would be undergoing and the length and implications of recovery post-treatment. This was a source of concern for the participants. CONCLUSION: The findings of this study suggest that there is a mismatch between the information provided to the families of people with CL/P and the levels of knowledge they have, about both their condition and the treatment options available to them. It is essential that clear, accessible information is provided at the right times in the care pathway to ensure that patients are able to make informed decisions about treatment.

Expressing Uncertainty in Dental Age Estimation: A Comparison between Two Methods of Calculating the "Average" Standard Deviation.

The expression of uncertainty is defined by the standard deviation and is usually expressed in multiples of the standard deviation (±1sd, ±2sd, and ±3sd). The objective was to use weighting of the sd calculation by the number or count of subjects for each tooth development stage. A comparison shows the difference between the range of uncertainty using the unweighted sd and the weighted sd. The range of uncertainty related to Dental Age Estimation is statistically significantly greater (p < 0.001) for the weighted sd compared to the unweighted sd. It is concluded that the number of subjects for each Tooth Development Stage in the Reference Data set should be included in the calculation for a single Dental Age Estimation using the Simple Average Method when presenting the uncertainty associated with the point estimate of the "mean" for Dental Age Estimation of a single subject of unknown age.

Examining Cardiomyocyte Dysfunction Using Acute Chemical Induction of an Ageing Phenotype.

Much effort is focussed on understanding the structural and functional changes in the heart that underlie age-dependent deterioration of cardiac performance. Longitudinal studies, using aged animals, have pinpointed changes occurring to the contractile myocytes within the heart. However, whilst longitudinal studies are important, other experimental approaches are being advanced that can recapitulate the phenotypic changes seen during ageing. This study investigated the induction of an ageing cardiomyocyte phenotypic change by incubation of cells with hydroxyurea for several days ex vivo. Hydroxyurea incubation has been demonstrated to phenocopy age- and senescence-induced changes in neurons, but its utility for ageing studies with cardiac cells has not been examined. Incubation of neonatal rat ventricular myocytes with hydroxyurea for up to 7 days replicated specific aspects of cardiac ageing including reduced systolic calcium responses, increased alternans and a lesser ability of the cells to follow electrical pacing. Additional functional and structural changes were observed within the myocytes that pointed to ageing-like remodelling, including lipofuscin granule accumulation, reduced mitochondrial membrane potential, increased production of reactive oxygen species, and altered ultrastructure, such as mitochondria with disrupted cristae and disorganised myofibres. These data highlight the utility of alternative approaches for exploring cellular ageing whilst avoiding the costs and co-morbid factors that can affect longitudinal studies.

Efficiency and effectiveness of orthodontic treatment within United Kingdom secondary care: a service evaluation.

OBJECTIVES: To evaluate the efficiency and effectiveness of Orthodontic treatment in the National Health Service (NHS) hospitals in England and to identify factors that may be predictive of the duration of Orthodontic treatment and number of patients' visits. DESIGN: Retrospective service evaluation. SETTING: The orthodontic departments of two NHS hospitals. METHODS: The data were collected from the clinical notes, the hospital data base and the pre- and post-treatment study models of 70 patients who were treated with fixed appliances. The pre- and post-treatment models were assessed using the Index of Orthodontic Treatment Need (IOTN) and the Peer Assessment Rating (PAR) index. RESULTS: (1) 98.5% of the patients treated with fixed appliances in both hospitals were in definite need for treatment, (2) The mean percentage PAR score reduction was 81.5%, (3) The mean treatment duration was 27 months with an average of 21 appointments, (4) Factors increasing treatment duration included being a female patient, class I malocclusion, IOTN 5, extractions, prescribing headgear wear, using functional appliances or quadhelixes and increased number of missed appointments, (5) Factors reducing the treatment time were male patients, class II or class III malocclusions and an increased number of emergency appointments. CONCLUSIONS: The hospitals demonstrated a high standard of orthodontic treatment.

A Bag of Marbles: A Fascinating Compound Odontoma of the Maxilla.

Odontomas are the most common odontogenic tumors, typically diagnosed during the first two decades of life. 1 The purpose of this paper was to report an interesting case of an eight-year-old Caucasian boy who presented with an asymptomatic, progressive, firm swelling of the right maxilla with no eruption of the permanent maxillary right lateral incisor. Radiographic investigation revealed a mixed radiolucent and radiopaque lesion measuring 28 by 24 by 17 mm with a corticated border causing expansion and thinning of the buccal cortical plate. This large bag-of-marbles-like appearance representing odontoids was impeding his adult teeth from erupting; hence, complete surgical removal under general anesthesia was the treatment of choice. Removal of the lesion resulted in an unexpected loss of the embedded permanent maxillary right lateral incisor. Histopathological investigations gave a diagnosis of compound odontoma; due to their low growth potential, recurrence after removal is not expected.

The mesially impacted mandibular third molar: The incidence and consequences of distal cervical caries in the mandibular second molar.

AIMS: Distal Cervical Caries (DCC) of the mandibular second molar (Md2M) is primarily related to retained mesially impacted third molars (Md3M). Treatment of this condition indicates the removal of the Md3M and the restoration of the Md2M and, on occasions, the loss of the Md2M. The aim of this study was to determine the incidence, treatment outcomes for patients, and calculate costs related to Md2M DCC. METHODS: A review of 121 patients who had Md3M removed due to Md2M DCC was undertaken to determine the treatment outcomes for patients. The number of patients affected by DCC of Md2M was calculated from the incidence of DCC (15%) in a cohort of patients requiring Md3M removal (1100) and the annual number of patients undergoing third molar surgery in England. Direct costs were calculated using NHS and independent treatment tariffs and indirect costs from Office of National Statistics (ONS). RESULTS: It is estimated that 152,000 patients in England undergo third molar removal on an annual basis. Approximately 27,000 Md3M are removed annually due to DCC of the Md2M; costing £27 m to treat with additional costs of £28 m if dental implant replacement of the Md2M is included. Total cost for treating Md2M DCC: £55 m/annum. CONCLUSIONS: Treating Md2M DCC and its consequences is expensive for healthcare funders such as the NHS and for patients. Md2M DCC is avoidable if patients who are at risk have prophylactic Md3M removal. This would offer potential and substantial savings in the financial cost of treating an otherwise avoidable disease.

Cleft lip and palate in context: Learning from, and adding to, the sociological literature on long-term conditions.

Cleft lip and palate is a common congenital anomaly affecting males and females. While there is psychological research on cleft lip and palate, there is relatively little research exploring the social context of cleft lip and palate and the experiences of living with the condition on a daily basis. Drawing on common themes emerging from sociological work which have explored the experiences of people living with long-term conditions (uncertainty, social relations, self-esteem and self-image and biomedical concerns), we argue that these themes can be used to help elucidate the experiences of people living with cleft lip and palate. Within this framework, the findings of a qualitative study exploring the experiences of people living with cleft lip and palate are presented. The results suggest that all four themes can be found within the accounts of people living with cleft lip and palate, and there are many commonalities between the experiences of these people and those living with other long-term conditions. Conversely there are interesting areas of divergence. Unlike most long-term conditions, cleft lip and palate is not degenerative and treatment means symptoms will reduce over time. This is reflected in narratives around 'normality' as the endpoint of the care pathway. In addition, prenatal diagnosis means that the vast majority of participants within this study were born into, and grew up within, the care pathway. This has implications for the way in which cleft lip and palate is understood and the provision of information, relationships with members of the care team over time and the temporal and contextualised impact of cleft lip and palate on social relations and the self.

How is adult patient adherence recorded in orthodontists' clinical notes? A mixed-method case-note study.

BACKGROUND: Patient adherence in orthodontic treatment is extremely important as it is linked with better treatment outcomes. Despite its importance, however, there is no shared definition of the concept. This makes the recording of adherence-related behaviors in patient notes difficult. The current study explored how, and to what extent adherence is recorded in adult patients' medical records by orthodontists working in a large National Health Service (NHS) London hospital. MATERIALS AND METHODS: A mixed-methods approach was used. A total of 17 clinicians with a mean age of 31 years (SD =4.87) provided N=20 case notes spanning N=324 appointments with patients they judged to be non-adherent. The notes were inspected for evidence of recording of patient adherence using adherence indicators identified in the literature. RESULTS: The term "adherence" did not feature in any notes. The quantitative analysis showed that the three most frequent adherence-related behaviors recorded in notes were "oral hygiene," "appointment attendance" and "breakages of appliances." Qualitative analysis not only confirmed these factors but also showed that 1) the clinical aspects of treatment, 2) clinician-patient interaction factors and 3) patient attitudes also featured. This part of the analysis also highlighted inconsistencies across case notes in terms of the amount of information being recorded. CONCLUSION: Adherence as a term does not feature in the clinical case notes of clinician-identified non-adherent adult patients, while predictors of adherence are recorded with varying degrees of consistency.

Validation of a new three-dimensional imaging system using comparative craniofacial anthropometry.

BACKGROUND: The aim of this study is to validate a new three-dimensional craniofacial stereophotogrammetry imaging system (3dMDface) through comparison with manual facial surface anthropometry. The null hypothesis was that there is no difference between craniofacial measurements using anthropometry vs. the 3dMDface system. METHODS: Facial images using the new 3dMDface system were taken from six randomly selected subjects, sitting in natural head position, on six separate occasions each 1 week apart, repeated twice at each sitting. Exclusion criteria were excess facial hair, facial piercings and undergoing current dentofacial treatment. 3dMDvultus software allowed facial landmarks to be marked and measurements recorded. The same measurements were taken using manual anthropometry, using soluble eyeliner to pinpoint landmarks, and sliding and spreading callipers and measuring tape to measure distances. The setting for the investigation was a dental teaching hospital and regional (secondary and tertiary care) cleft centre. The main outcome measure was comparison of the craniofacial measurements using the two aforementioned techniques. RESULTS: The results showed good agreement between craniofacial measurements using the 3dMDface system compared with manual anthropometry. For all measurements, except chin height and labial fissure width, there was a greater variability with the manual method compared to 3D assessment. Overall, there was a significantly greater variability in manual compared with 3D assessments (p < 0.02). CONCLUSIONS: The 3dMDface system is validated for craniofacial measurements.

Mentolabial angle and aesthetics: a quantitative investigation of idealized and normative values.

BACKGROUND: This study is a quantitative evaluation of the influence of the mentolabial angle on perceived attractiveness and threshold values of desire for surgery. METHODS: The mentolabial angle of an idealized silhouette male Caucasian profile image was altered incrementally between 84° and 162°. Images were rated on a Likert scale by pretreatment orthognathic patients (n = 75), lay people (n = 75) and clinicians (n = 35). RESULTS: A mentolabial angle of approximately 107° to 118° was deemed the most attractive, with a range of up to 140° deemed acceptable. Angles above or below this range were perceived as unattractive, and anything outside the range of below 98° or above 162° was deemed very unattractive. A deep mentolabial angle (84°) or an almost flat angle (162°) was deemed the least attractive. In terms of threshold values of desire for surgery, for all groups, a threshold value of ≥162° and ≤84° indicated a preference for surgery, although clinicians were least likely to suggest surgery. The clinician group was the most consistent, and for many of the images, there was some variation in agreement between clinicians and lay people as to whether surgery is required. There was even more variability in the assessments for the patient group. CONCLUSIONS: It is recommended that in orthognathic and genioplasty planning, the range of normal variability of the mentolabial angle, in terms of observer acceptance, is taken into account as well as threshold values of desire for surgery. The importance of using patients as observers in attractiveness research is stressed.

Dental Age Estimation-Root Pulp Visibility (RPV) patterns: A reliable Mandibular Maturity Marker at the 18 year threshold.

The purpose of this paper was to explore the potential application of Root Pulp Visibility (RPV) to determine whether or not a subject of unknown date of birth is under or over the 18year threshold. PATIENTS, MATERIALS AND METHODS: Two thousand Dental Panoramic Radiographs comprising equal numbers of females and males evenly distributed between the ages of 16 and 26 years were examined. All third molars were scored using the Anglo-Canadian 8 Stage Tooth Development system [1]. The Lower Left Third Molar was censored to avoid redundant data being included in the data array for the Age at Attainment of Stage H, the final stage of tooth development (Roberts et al., 2015 [2]). A filter cascade was applied to the data to select the data array for 1. Teeth in the final stage of development, 2. Female or male gender, 3. The definitive stage of RPV: RPV-A, RPV-B, RPV-C, or RPV-D. RESULTS: The summary data for each of these stages was derived and the minimum value for each was used to determine the relationship of the minimum value of A, B, C or D to the 18 Year threshold. It was found that for both females and males the minimum value for RPV-A and RPV-B indicated that subjects displaying this could be under 18 years old. For RPV-C and RPV-D, the minimum values show unequivocally that for both females and males the subject was over 18 years old. CONCLUSION: RPV has an important role in unambiguously determining whether a subject is below or above the 18year threshold.

Dental Age Estimation: Pattern Recognition of Root Canal Widths of Mandibular Molars. A Novel Mandibular Maturity Marker at the 18-Year Threshold.

The final stage of third molar development is used to assign a subject to above the 18-year threshold. Some subjects exhibiting this final stage are less than 18 years. Radiographs from 1000 females and 1000 males age 16.00-25.99 years were examined. Each half-year age band comprised 50 females and 50 males. Three categories of root canal widths (RCW) of the LL6, LL7, and LL8 [FDI 36, 37, and 38] were defined. Reproducibility was achieved by re-assessing the same subjects 12 months apart. For females, the minimum value for RCW-A was 16.33 years, RCW-B 17.23 years, and RCW-C 18.45 years. For males, the minimum values were RCW-A 17.16 years, RCW-B 18.29 years, and RCW-C 18.16 years. The presence of RCW-C in a female, and the presence of RCW-B or RCW-C in a male is compelling evidence that the subject is above the 18-year threshold.

Dental age estimation of children and adolescents: Validation of the Maltese Reference Data Set.

The purpose of this study was to validate a Reference Data Set, developed from the radiographic archives of the Dental Department, Mater Dei Hospital, Malta, for Dental Age Estimation of the Maltese population and to assess the accuracy of the method. Dental Panoramic Tomograms of 100 male and 100 females were selected. Tooth Development Stages were recorded for all 16 permanent teeth on the left and both third molars on the right. Summary and percentile data were calculated for each Tooth Development Stage and the Dental Age of each subject estimated using the unweighted average method. The distribution of the differences between the Dental and Chronological age was analysed. There was no statistically significant difference between the means of the Dental and Chronological ages and the mean differences were within acceptable limits. The conclusion was that the Dataset is valid for the Maltese population and the method used gives adequate accuracy.

Dental age estimation: periodontal ligament visibility (PLV)-pattern recognition of a conclusive mandibular maturity marker related to the lower left third molar at the 18-year threshold.

The purpose of this study was to explore the applicability of periodontal ligament visibility (PLV) at the 18-year threshold. This mandibular maturity marker is graded into four separate age related stages, PLV-A, PLV-B, PLV-C, and PLV-D. These are discernible on a dental panoramic tomograph (DPT). The sample comprised a total of 2000 DPTs evenly divided into half yearly age bands from 16.00 to 25.99 years with 50 females and 50 males in each age band. It was found that PLV-A and PLV-B had minimum values below the 18-year threshold. PLV-C and PLV-D in females had minimum values of 18.08 and 18.58 years, respectively. In males, the minimum values for PLV-C was 18.10 years and PLV-D was 18.67 years. It was concluded that the presence of PLV-C or PLV-D indicates that a subject is over 18 years with a very high level of probability.

Submental-Cervical Angle: Perceived Attractiveness and Threshold Values of Desire for Surgery.

AIM: The submental-cervical angle may alter as a result of mandibular orthognathic surgery and/or the ageing process and is therefore an important facial aesthetic parameter for comparative diagnosis and treatment planning. The purpose of this study was to undertake a quantitative evaluation of the influence of the submental-cervical angle on perceived attractiveness and threshold values of desire for surgery. STUDY DESIGN: The submental-cervical angle of an idealized profile silhouette image was altered incrementally between 90° and 130°. The images were rated on a seven-point Likert scale by pre-treatment orthognathic patients (n = 75), laypeople (n = 75), and clinicians (n = 35). RESULTS: A submental-cervical angle of 90°-105° was deemed acceptable. Angles up to 120° were deemed slightly unattractive by the lay and clinician groups, but very unattractive by the patient group. By 125°-130° all groups perceived the angle as very unattractive. The threshold value of desire for surgery was 110° for patients, 115° for lay people and 125° for clinicians. Patients appear to be more critical than lay and clinician groups. CONCLUSIONS: These ranges of normal variability of the submental-cervical angle and threshold values of desire for surgery, in terms of observer acceptance, should be considered by clinicians in planning mandibular orthognathic surgery and aesthetic surgical procedures of the submental-cervical region.

Nasofrontal Angle and Nasal Dorsal Aesthetics: A Quantitative Investigation of Idealized and Normative Values.

This study is a quantitative evaluation of the influence of the lower component of the nasofrontal angle on perceived attractiveness and threshold values of desire for rhinoplasty. The nasofrontal angle of an idealized silhouette male Caucasian profile image was altered incrementally between 106 and 148 degrees. Images were rated on a Likert scale by pretreatment patients (n = 75), laypeople (n = 75), and clinicians (n = 35). The results demonstrated that a nasofrontal angle of approximately 130 degrees is ideal, corresponding to a lower component of 60 degrees, with a range of 127 to 142 degrees deemed acceptable. Angles above or below this range are perceived as unattractive, and anything outside the range of 118 to 145 degrees is deemed very unattractive. Reduced nasofrontal angles, simulating a nasal hump deformity, of less than 115 degrees were deemed the least attractive. In terms of threshold values of desire for surgery, for all groups a threshold value of 148 degrees indicated a preference for surgery: for patients, the threshold value was 121 degrees or less; for lay people, the threshold value was 124 degrees or less; and similarly for clinicians, the threshold value was 118 degrees or less. Clinicians were the least critical, and patients appeared to be less critical than lay people. This stresses the importance of using patients as observers, as well as laypeople and clinicians, in facial attractiveness research. From the results of this study, it is recommended that in rhinoplasty planning, the range of normal variability of the nasofrontal angle, in terms of observer acceptance, is taken into account as well as the threshold values of desire for surgery.

Dental Age Estimation: A Test of the Reliability of Correctly Identifying a Subject Over 18 Years of Age Using the Gold Standard of Chronological Age as the Comparator.

This study was designed to test the reliability of using the third molars to demarcate between child and adult status. A total of 2000 dental panoramic tomographs were used for assessment of the calculated age using the 8-stage system of tooth development and applied to all four third molars. The LL8 was also assessed using this 8-stage system. For each tooth development stage, the Normal distribution and percentile summary data were estimated. The calculated dental age compared with the chronological age was statistically significantly different (p < 0.001) for both females and males giving underestimates of the true age. Comparison of single tooth dental age and chronological age was only slightly different. The most important finding is that the assignment to above or below the 18-year threshold, in the age range 17 years to 19 years, could be wrong on up to 50% of occasions.