Motivation, Perception, and Behavior of the Adult Orthodontic Patient: A Survey Analysis.

Purpose: The article is aimed at improving the understanding of the sociocultural profile of adult orthodontic patients and their expectations. In particular, it addresses three main aspects: the motivation and needs that underpin the decision to start orthodontic treatment, how it influences the patients' daily life, and the different oral hygiene demands. Materials and Methods: An online survey was completed by 276 patients undergoing orthodontic treatment with different techniques. The questions asked concerned gender, age, type of appliance, any previous orthodontic treatments, type of any previous retainers, reasons for therapy, satisfaction, pain, problems in eating, daily number of teeth brushings and flossings before and during the treatment, perception of cost, sensation of visibility of the appliance, and if they would recommend orthodontic treatment. Results: A significant role within our sample is played by gender; 87.94% consisted of female patients out of which 72.57% wanted to improve their aesthetics, while only 54.84% of male patients cited the same reason. Invisible aligners were preferred by 67.70% of the patients due to them being considered the least painful, causing the fewest problems with eating, and the least visible. Metal braces were perceived as the less expensive treatment. Over a third of the patients (33.85%) had previously undergone orthodontic treatment, among them 54.05% wore a mobile retainer, 31.08% a fixed one, and 14.86% both. Daily tooth brushing and flossing increased during therapy with clear aligners by 48.94% and 126.39%, respectively. Conclusions: The greatest demand for orthodontic treatments comes from women, as they pay more attention to aesthetics, which makes the clear aligners the most common choice. The relapse after orthodontic treatment seems to cause a higher demand for retreatment, and oral hygiene habits significantly improve during orthodontic treatment, especially with the clear aligners.

Study of cellular toxicity in vitro of two resins for orthodontic use.

OBJECTIVE: The objective of this work is to compare cellular toxicity in vitro of two resins for orthodontic use: an auto-polymerizable composite and a photo-polymerizable composite. MATERIALS AND METHODS: Samples were obtained by joining a couple of steel orthodontic brackets by using auto-polymerizing or photo-polymerizing resin. We used a halogen lamp, a mini LED lamp and a fast LED lamp used for orthodontics cure for 40 seconds. The 3T3 Swiss cellular line of fibroblasts was used. The samples obtained were used to determine the cellular toxicity in vitro using the Neutral Red Up-take (NRU) and the 3-(4,5-dimethylthiazol-2-Yl)-2,5-diphenyltetrazolium bromide (MTT) assay. RESULTS: Toxicity of the extract appraised at a low level at MTT and NRU assays. There were statistically relevant differences between the toxicity induced by the auto-polymerizing material and the toxicity induced by the photo-polymerizing composite material, polymerized with the blue-light lamp (p < 0.001) and with the mini LED lamp (p < 0.05). CONCLUSIONS: From the data collected in this study, we can conclude that both resins show a low level of cytotoxicity that, in the case of photochemical polymerizing resin, depends on the characteristics of the lamp.

Association between oral habits, mouth breathing and malocclusion in Italian preschoolers.

AIM: This cross-sectional study was carried out to evaluate the prevalence of malocclusion and associated factors in preschoolers with the aim of assessing the existence of an association between bad habits and mouth breathing with the most severe malocclusions. MATERIALS AND METHODS: A sample of 1616 children aged 3-6 years was visited by applying the Baby ROMA index, an orthodontic treatment need index for preschool age. The following were searched: the prevalence of malocclusion, the association of bad habits and mouth breathing with malocclusion, how often are found in association and how this association is statistically significant. Chi-square and Fischer test were applied to verify the statistical significance of the association between the variables. RESULTS: The data show that 38% of the sample need orthodontic treatment and 46% have signs of malocclusion of less severe degree that require a close monitoring and the elimination of risk factors so that they can improve spontaneously with growth. Moreover the prevalence of bad habits and oral breathing increases with increasing severity of the malocclusion, and sucking habits and oral breathing are both closely related to anterior open bite, posterior crossbite and increased overjet. CONCLUSIONS: In the context of prevention and early treatment of disorders of the craniofacial growth, bad habits and mouth breathing, being risk factors of malocclusion, should be intercepted and corrected early on to prevent the development of malocclusion, or the worsening of existing ones. From this point of view it is important to follow the patients with a multidisciplinary approach.

Proposal for a myofunctional therapy protocol in case of altered lingual frenulum. A pilot study.

In this article, the authors propose a specific Myofunctional Therapy Protocol for patients with altered lingual frenulum. In such cases tongue muscles are hypofunctioning and their range of motion is reduced. To compensate for this limitation, dysfunctional lingual motor patterns are established, such as the use of some muscles at the expense of others; this negatively affects the development and functions of the stomatognathic system. The Myofunctional Therapy Protocol presented in this pilot study was developed with the aim of making the muscles of the tongue, the floor of the mouth and the soft palate more coordinated, and increasing muscle contraction strength, in order to produce improvements on the muscle tone, on orofacial and nasal functions and a better wound healing and functional recovery in the case of surgical therapy (frenulotomy).

Skeletal stability in orthognathic surgery with the surgery first approach: a systematic review.

The surgery first approach (SFA) is a therapeutic strategy used in orthognathic surgery that is constantly evolving. With this approach, the pre-surgical orthodontic treatment can be eliminated, the maxilla and the mandible are surgically repositioned into the desired position, and the therapy is ended with a short orthodontic phase. Several studies have reported that the SFA is an acceptable approach, but postoperative stability is unclear. In this study, a systematic review on the SFA was performed. The PubMed, Google Scholar, Scopus, LexisNexis, Web of Science, and Cochrane Library databases were accessed. Studies from which data could be extracted on skeletal stability based on specific cephalometric points were included. The search yielded 2766 publications. Application of the selection criteria resulted in a final group of 14 articles. Five hundred and sixty patients with class III malocclusion underwent orthognathic surgery, 339 with the SFA. Study parameters such as evaluation time points and reference planes varied, making it impossible to perform a meta-analysis. The studies suggest that surgery with the SFA is as stable as surgery with the conventional approach. However, all articles described stability using a penultimate time point of 'after surgery' and not 'after debonding'; hence orthodontic movements and consequent mandibular movements could have influenced cephalometric measurements. Thus, to verify the real stability of the SFA, further research with longer follow-up periods is required, with evaluation at the same time points.

Interceptive treatment in ectodermal dysplasia using an innovative orthodontic/prosthetic modular appliance. A case report with 10- year follow-up.

AIM: The treatment of a complex case of hypohidrotic ectodermal dysplasia (HED) with severe oligodontia. CASE REPORT: A 6 years old boy with HED, was treated with an orthodontic/prosthetic modular appliance. The device is custom made and consists of two parts, upper and lower, which were partially removable and partially fixed. The patient was prepared to receive dental implants for definitive oral rehabilitation. The treatment begun with heath-cured acrylic resin removable appliance with expansion screw in the maxilla and in the mandible. Afterwards, an innovative orthodontic/prosthetic modular appliance was made in the maxilla and in the mandible, fixed with bands on the first permanent molars, with expansion screw and telescopic screw that follow and support the resin prosthetic teeth during the orthopaedic expansion. The resin prosthetic teeth are removable from the metallic fixed structure of this appliance.The patient was followed for 10 years from the beginning of treatment. CONCLUSION: The modular appliance here described and our therapeutic approach showed to be efficient and durable in the achievement of many goals in the treatment of a complex case of HED. The objectives were not only just orthodontic, but also prosthetic and psychological.

A specific protocol of myo-functional therapy in children with Down syndrome. A pilot study.

In this article the authors propose a specific myofunctional therapy protocol for children with Down syndrome. For these patients, who usually present with atypical swallowing problems, mouth breathing and lip incompetence, the use of a myofunctional therapy protocol with specific exercises has been shown to improve orofacial and nasal functions. In addition to the functional results, such as the correction of the atypical swallowing, restoration of lip competence, breathing improvement and reduction of nasal rhinorrhea, there were also aesthetic results. This protocol can be useful to improve the quality of life of these patients.

Retrospective epidemiological study of mandibular rotational types in patients with orthodontical malocclusion.

SUMMARY: The primary aim of this study was to illustrate the prevalence of facial skeletal discrepancy in an Italian sample. Another aim was to evaluate the effectiveness of the sagittal skeletal discrepancy classification in order to establish a morphologic pattern of growth useful for diagnosis and prediction of therapeutic results. The authors considered a sample of 732 patients (426 females and 306 males) aged between 6 and 17 years old. Cephalometric parameters were evaluated in order to establish a relationship between sagittal skeletal discrepancy and the classification of facial rotations (Lavergne and Petrovic). Facial types with neutral mandibular growth direction were the most prevalent, and were most observed in classes I and II; the latter was more represented than others in our sample. Facial types with posterior mandibular growth direction were the most prevalent in class III. Sagittal skeletal discrepancy classification is not able to establish a specific facial type or predict an individual responsiveness to treatment.

Association between oral habits, mouth breathing and malocclusion.

The ratio of bad habits, mouth breathing and malocclusion is an important issue in view of prevention and early treatment of disorders of the craniofacial growth. While bad habits can interfere with the position of the teeth and normal pattern of skeletal growth, on the other hand obstruction of the upper airway, resulting in mouth breathing, changes the pattern of craniofacial growth causing malocclusion. Our crosssectional study, carried out on 3017 children using the ROMA index, was developed to verify if there was a significant correlation between bad habits/mouth breathing and malocclusion. The results showed that an increase in the degree of the index increases the prevalence of bad habits and mouth breathing, meaning that these factors are associated with more severe malocclusions. Moreover, we found a significant association of bad habits with increased overjet and openbite, while no association was found with crossbite. Additionally, we found that mouth breathing is closely related to increased overjet, reduced overjet, anterior or posterior crossbite, openbite and displacement of contact points. Therefore, it is necessary to intervene early on these aetiological factors of malocclusion to prevent its development or worsening and, if already developed, correct it by early orthodontic treatment to promote eugnatic skeletal growth.

The role of masseter muscle EMG during DISE to predict the effectiveness of MAD: preliminary results.

The use of a mandibular advancement device (MAD) increases the activity of the temporo-mandibular (TM) complex and masseter (MM) muscles with the risk of reducing treatment compliance. Predictors of treatment outcome are of importance in selecting patients who might benefit from MAD without side effects. The role of mandibular advancement (MA) during drug-induced sleep endoscopy (DISE) is controversial. In three cases (BMI < 30) affected by non-severe OSAS (AHI < 30 e/h), we recorded the surface EMG signal of MM activity during DISE. At follow-up all cases improved the AHI, two cases that showed transient increase of MM activity did not suffer from changes of overjet and did not complain of discomfort with the use of MAD. The case that showed a continuing increase of MM activity reported TM discomfort without changes of dental occlusion. EMG of MM during DISE may contribute to ameliorate the selection of cases amenable to treatment with MAD.

Drug-induced sleep endoscopy as a selection tool for mandibular advancement therapy by oral device in patients with mild to moderate obstructive sleep apnoea.

Nowadays oral appliance therapy is recognised as an effective therapy for many patients with primary snoring and mild to moderate obstructive sleep apnoea (OSA), as well as those with more severe OSA who cannot tolerate positive airway pressure (PAP) therapies. For this reason, it is important to focus on objective criteria to indicate which subjects may benefit from treatment with a mandibular advancement device (MAD). Various anthropometric and polysomnographic predictors have been described in the literature, whereas there are still controversies about the role of drug-induced sleep endoscopy (DISE) and advancement bimanual manoeuvre as predictor factors of treatment outcome by oral device. Herein, we report our experience in treatment of mild moderate OSA by oral appliance selected by DISE. We performed a single institution, longitudinal prospective evaluation of a consecutive group of mild moderate patients with obstructive sleep apnoea syndrome who underwent DISE. During sleep endoscopy, gentle manoeuvre of mandibular advancement less than 5 mm was performed. In 30 of 65 patients (46.2%) we obtained an unsuccessful improvement of airway patency whereas in 35 of 65 patients (53.8%) the improvement was successful and patients were considered suitable for oral device application. Because 7 of 35 patients were excluded due to conditions interfering with oral appliance therapy, we finally treated 28 patients. After 3 months of treatment, we observed a significant improvement in the Epworth medium index [(7.35 ± 2.8 versus 4.1 ± 2.2 (p < 0.05)], in mean AHI [(21.4 ± 6 events per hour versus 8.85 ± 6.9 (p < 0.05)] and in mean ODI [(18.6 ± 8 events per hour to 7 ± 5.8 (p < 0.05)]. We observed that the apnoea/hypopnoea index (AHI) improved by up to 50% from baseline in 71.4% of patients selected after DISE for MAD therapy. In the current study, mandibular advancement splint therapy was successfully prescribed on the basis not only of severity of disease, as determined by the subject's initial AHI, but also by DISE findings combined with results of gentle mandibular advancement manoeuvre allowing direct view of the effects of mandibular protrusion on breathing spaces in obstruction sites, and showing good optimisation of selection of patients for oral device treatment.

Early orthodontic treatment: a new index to assess the risk of malocclusion in primary dentition.

AIM: A new index targeted on the risk of malocclusions in primary dentition, called Baby-ROMA (Risk Of Malocclusion Assessment) index, was set up to assess risks/benefits in early orthodontic therapies. The Baby-ROMA index was designed from the observation that some of the malocclusion signs, observed in primary dentition, can worsen with growth, others remain the same over time and others can even improve. Therefore it would be important to classify the malocclusions observed at an early stage on a risk- based scale. MATERIALS AND METHODS: The reliability of the index was tested on 200 children, referred by their paediatricians to two different Orthodontic Departments, aged 4-6 years and in full primary dentition. The children were evaluated by two operators, both trained and calibrated on the use of the Baby-ROMA index. RESULTS: The K test showed a high reproducibility of the index. It is shown that 50% of patients presented malocclusion and crossbite had the highest prevalence, followed by tooth decay and early loss of deciduous teeth and negative overjet. CONCLUSION: The Baby-ROMA index was helpful to assess the severity of malocclusion and the timing for orthodontic treatment in very young patients (primary teeth).

Orthodontic treatment timing in growing patients.

AIM: The aim of the study is to estimate the orthodontic treatment timing for the main occlusal problems in growing patients. STUDY DESIGN: a cross-sectional study was carried out in Italian primary and secondary schools from 2008 to 2011; 1375 males and 1642 females, aged between 8 and 13 years, were visited. The sample is divided into two main groups: primary school and secondary school. Selected malocclusion signs were registered according to an occlusal index (ROMA index) by trained and calibrated operators. Prevalence of increased overjet, Class III malocclusion, crossbite, deep bite and open bite observed in each group are compared. A significant decrease of prevalence with age is considered a sign of spontaneous improvement of the malocclusion. RESULTS: Descriptive analyses were performed using frequencies, percentages and chi-square tests to evaluate differences for categorical variables. The level of significance was set at p ≤0.05. Data were analysed with the software SPSS 19.0 for Windows. Class III malocclusion, moderate or severe crossbite and severe increased overjet and overbite seem not to improve spontaneously. CONCLUSION: Early treatment of orthodontic problems that do not improve with age may be helpful to avoid worsening of the condition in permanent dentition. Moderate Class II malocclusion and crossbite treatment can be postponed.

Prevalence of malocclusion in Italian schoolchildren and orthodontic treatment need.

AIM: The aim of the study was to estimate the prevalence of malocclusion and the need for orthodontic treatment in a sample of 3,017 Italian schoolchildren. STUDY DESIGN: 1,375 males and 1,642 females, aged between 8 and 13 years, were visited in primary and secondary schools. Signs of malocclusion were registered according to an occlusal index by trained and calibrated operators. First the prevalence of malocclusion was calculated in accordance to a scale of need for orthodontic treatment (R.O.M.A. index), which considers both malocclusion signs and risk factors for worsening of malocclusion without any treatment and during craniofacial development. Then the distribution of the most frequent characteristics, signs and symptoms was evaluated both within each risk grade and in the basic sample. RESULTS: The overall percentage of children classified as 3, 4 and 5 grade accounted for 75.8% of the sample. The percentage of children classified as 4 and 5 grade are similar to those found in other European countries. The most frequent features found are poor oral hygiene, caries and early loss of deciduous teeth, deviation from full intercuspation, increased overbite and overjet. CONCLUSION: This epidemiological research describes the current orthodontic treatment need in Italy in children with a late mixed dentition.

Orthodontic treatment need in the Italian child population.

AIM: To assess orthodontic treatment need in the Italian child population using the R.O.M.A. (Risk Of Malocclusion Assessment) Index. STUDY DESIGN: Observational study (cross-sectional). MATERIALS, METHODS AND RESULTS: The ROMA Index was used in examining a sample of 420 children (214 males and 206 females; mean age: 9.3 years), none of whom had previously undergone orthodontic treatment. This basic sample was large enough to become the object of an epidemiological study and to be analysed through inferential statistics. After calculating the prevalence of malocclusion on the basis of the degrees of orthodontic risk determined by the Index, we evaluated the distribution of the most frequent characteristics, signs and symptoms within each risk grade. The percentage of children in each risk category was then worked out, together with its 95% confidence interval, in order to verify whether our results could be generalised to the reference population. Significantly, 50% of the examined children were classified as 'at moderate risk', as defined by grade 3 of the Index (non-severe alterations in dental and/or skeletal relationships, but tending to persist and often worsen with growth). Equally remarkably, a further 36% fell within grade 4 of the Index ('great risk'), presenting major craniofacial skeletal malformations and alterations of the occlusion, often in association with systemic or growth disorders likely to worsen the prognosis. Thus, since patients at moderate or great risk amounted to 86% of the basic sample, it appears that our estimate can be generalised to the reference population of Italian pre-adolescent children. CONCLUSION: The study showed a high percentage of children at moderate or great risk (86%), and that this estimate can be generalised to the reference population of Italian pre-adolescent children. These findings should be taken into great account in devising strategies to improve patient service quality, whether in public or private settings, and also in planning preventive measures and interventions.

Satisfaction with dental appearance in 8-9 years-old children. Validation of COAS questionnaire for Italian-speaking children and evaluation of social and geographical context.

AIM: This study was designed to adapt the original English-language COAS (Children's Orthodontic Attitude Survey) for third- grade schoolchildren to the Italian cultural environment and to investigate its properties in typical populations, as well as to evaluate children self-perception of their dental appearance. STUDY DESIGN: The COAS questionnaire for third-grade schoolchildren was translated and culturally adapted for Italian-speaking children. The Italian version of the questionnaire was tested on 169 (73 females, 96 males) children. Test-retest reliability was assessed on 34 children one week after the first administration. We also analysed correlations between social status and questionnaire findings. METHODS: All children filled in the questionnaire and then they were clinically examined by three residents. The clinical parameters were correlated with the questionnaire findings to evaluate children's satisfaction with their dental appearance. RESULTS: Ninety-five per cent of children thought it was important to have straight teeth and 87 per cent considered that crooked teeth were ugly. Comparison with clinical parameters showed a statistically significant correlation between crowding and overjet and some answers. Urban children have a better opinion on braces: they would like to have braces and they think they need braces statistically more than rural subjects. CONCLUSION: The Italian version of the modified-COAS questionnaire had a very good reliability. Social status and geographical context play a very important role in children's satisfaction with dental appearance. Children with different social context demonstrate they have very different approaches towards their dental aspect and braces.

Validation of the Risk Of Malocclusion Assessment (ROMA) index.

AIM: The aim of this study was to validate the ROMA (Risk Of Malocclusion Assessment) Index, verifying both its reproducibility and its ability to determine treatment priority. MATERIALS AND METHODS: The levels of treatment priority assessed for 75 children examined at the Gemelli General Hospital Orthodontic Service (Rome) ranged from grade 3 to grade 5 of the index. Multivariate analysis was conducted to verify the influence of covariates on the dependent variable. Moreover, the DHC of the IOTN was assessed for all patients, and a bivariate analysis was carried out to investigate its relationship with the ROMA Index. Intra- and inter- examiner reliability was calculated on a sample of 20 children, and the reproducibility of the index was evaluated using the Kappa statistic as a measure of concordance. RESULTS: It arose that there is an inverse relation between risk grades and the time interval from the first examination and start of treatment. According to the index, patients at extreme risk require immediate treatment, whereas priority is lower in case of great or moderate risk. In statistical terms, the study revealed a significant correlation between the ROMA Index and the DHC of the IOTN. With regard to intra- and inter-examiner reliability, the data collected by the two examiners showed a high level of agreement. CONCLUSION: The ROMA index appears quick to apply, reproducible, reliable and sensitive as a mean for carefully identifying different dento-skeletal problems. Furthermore, it is able to determine the priority of every risk grade and the corresponding timing of treatment.

Comparative evaluation between cervical vertebral morphology and hand-wrist morphology for skeletal maturation assessment.

AIM: The aim of the study was to find a correlation between the evaluation of skeletal maturation performed by the study of cervical vertebrae maturation indicators and the evaluation obtained by the hand and wrist maturation indicators. METHODS: Left hand wrist radiographs and the corresponding lateral cephalograms of 90 patients (48 males and 42 females; aged 6 to 14 years) were paired and a study group of 128 pair of radiographs was obtained, having some patients 2 or more radiographs at different times. Hand and wrist radiographs were evaluated according to the protocol proposed by Grave (scores 0 to 9); corresponding lateral cephalograms were evaluated according to the method reported by Baccetti (scores 1 to 5). Values obtained with the 2 methods were analyzed by Spearman's correlation test. RESULTS: When the values were compared globally in the 2 genders a good correlation was obtained (r=0.795; P<0.001); when the correlation was compared separately in the 2 genders a better correlation was observed in females (r=0.84; P<0.001) than in males (r=0.70; P<0.001). CONCLUSIONS: The results obtained clearly underline the accuracy of the skeletal maturation evaluation by the analysis of cervical vertebrae in laterolateral cephalograms which can substitute the hand and wrist radiograph for the skeletal maturation evaluation in orthodontic diagnosis.

Class III dento-skeletal anomalies: rotational growth and treatment timing.

AIM: The interception of a Class III malocclusion requires a long-term growth prediction in order to estimate the subject's evolution from the prepubertal phase to adulthood. The aim of this retrospective longitudinal study was to highlight the differences in facial morphology in relation to the direction of mandibular growth in a sample of subjects with Class III skeletal anomalies divided on the basis of their Petrovic's auxological categories and rotational types. MATERIALS AND METHODS: The study involved 20 patients (11 females and 9 males) who started therapy before reaching their pubertal peak and were followed up for a mean of 4.3 years (range: 3.9-5.5 years). RESULTS: Despite the small sample size, the definition of the rotational type of growth was the main diagnostic element for setting the correct individualised therapy. CONCLUSION: We therefore believe that the observation of a larger sample would reinforce the diagnostic-therapeutic validity of Petrovic's auxological categories, allow an evaluation off all rotational types, and improve the statistical significance of the results obtained.

[Height growth velocity and orthodontic treatment timing]. / Velocità di crescita e timing del trattamento ortodontico.

The auxologic evaluation, by periodic measurements of the height of children and the comparison of the values obtained with standard curves of growth, is a common practice for the pediatrician providing a precise indication on the general course of the growth and on the presence of possible growth pathologies. In fact, decelerations or pathological accelerations of growth can be a suspicious sign of endocrine, metabolic, genetic, gastric or tumoral diseases. The use of some growth variables and particularly the evaluation of the kinetics of statural height growth, should enter the daily practice of the orthodontist. In fact, the correspondence among peaks of statural and mandibular growth allows the orthodontist to choose the suitable time to intervene with the therapy aimed to stimulate the growth of the jaws. In this paper the authors report 2 orthodontic cases characterized by a malocclusion due to mandibular deficiency, in which the integration of the orthodontic and pediatric competences, through the use of the curves of the speed of growth and other growth variables, has allowed to reach optimal results, having achieved normal skeletal and occlusal relationships in the shorter time. The periodic measurement of height growth velocity represents a simple and safe method that allows to evaluate the kinetics of growth in children, with the remarkable advantage, unlike radiological examinations, to be repeated without any risk for the patient.