Direct versus fully digital indirect bracket bonding: a split-mouth randomized clinical trial on accuracy.

OBJECTIVES: The primary aim is to assess differences in accuracy of orthodontic bracket positioning between fully digital indirect bracket bonding (IDB) and conventional direct bracket bonding (DBB). The secondary aims are to assess differences in bracket bonding failures, bracket repositioning need, clinician experience and patient satisfaction. MATERIALS AND METHODS: This prospective study was designed as a split-mouth randomized clinical trial. In total, 35 patients were analyzed with a six month follow-up period. Translational and orientational deviations from the planned bracket position were determined. Clinician experience and patient satisfaction were evaluated by means of a survey. RESULTS: The difference in translation was 0.34 mm (95% CI: 0.238-0.352, p = 0.017), the difference in orientation was 4.80˚ (95% CI: 3.858-5.727, p < 0.001), both in favour of IDB. IDB showed significantly more immediate (IDB: 3.9%, DBB: 0%) and late (IDB: 5.4%, DBB: 2.5%, p = 0.008) bonding failures. Clinicians and patients experienced a shorter clinical chair time with indirect bonding over direct bonding. CONCLUSIONS: IDB bracket positioning leads to significant smaller translation and orientation deviations from digital IDB planning, than DBB bracket positioning. However, IDB leads to more immediate bonding failures than DBB. The majority of patients preferred IDB over DBB, due to a shorter clinical chair time. CLINICAL RELEVANCE: This study adds to the knowledge of IDB in orthodontics and contributes to evidence on this technique. This evidence is applicable in everyday orthodontics, with respect to patient satisfaction and technical limits of IDB. The trial was registered in the Dutch Trial Register and the International Clinical Trials Registry Platform (ICTRP) of the World Health Organization (WHO), number NL9411.

The effect of surface roughening on the success of orthodontic mini-implants: A systematic review and meta-analysis.

INTRODUCTION: Orthodontic mini-implants are a widely accepted treatment modality in orthodontics; however, the failure rate is moderately high. Surface roughening is the golden standard in conventional oral implantology, and this may prove beneficial for orthodontic mini-implants as well. The objective of this systematic review is to assess the effect of surface roughening on the success rate of orthodontic mini-implants in both adolescent and adult patients undergoing orthodontic treatment. METHODS: Randomized studies comparing the success of surface-roughened and smooth, machined-surface orthodontic mini-implants were included. A literature search was conducted for 6 electronic databases (Pubmed/Medline, Embase, Cochrane, CINAHL, Web of Science, and Scopus), Clinical trial registry (https://www. CLINICALTRIALS: gov), and grey literature (Google Scholar). A manual search of the reference lists of included studies was performed. Two authors independently performed the screening, data extraction, risk of bias, and quality assessments. The risk of bias was assessed with the Cochrane risk-of-bias 2.0 Tool. Data were synthesized using a random effect model meta-analysis presented as a forest plot. The certainty in the body of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation tool. RESULTS: A total of 4226 unique records were screened, and 6 of these were included in the quantitative analysis. Four additional articles were selected for a secondary outcome. A total of 364 orthodontic mini-implants were included in the primary outcome analysis. There was no statistically significant effect of surface roughening on the success of orthodontic mini-implants (odds ratio = 0.63 favoring roughened orthodontic mini-implants; 95% confidence interval, 0.35-1.14). The secondary outcome (ie, the overall failure rate of roughened orthodontic mini-implants) was 6% based on studies with high heterogeneity. Limitations of this study were the risk of bias, study imprecision, and possible publication bias, leading to a very low certainty in the body of evidence. CONCLUSIONS: There is very low-quality evidence that there is no statistically significant effect of surface roughening on the success of orthodontic mini-implants in humans. The overall failure rate of surface-roughened orthodontic mini-implants was 6%. FUNDING: No funding was received for this review. REGISTRATION: This study was preregistered in the Prospective Register of Systematic Reviews (CRD42022371830).

Classification Systems of Cleft Lip, Alveolus and Palate: Results of an International Survey.

OBJECTIVE: This study aimed to identify commonly used classification systems by cleft providers around the world, including the perceived indications and limitations of each system. DESIGN: A cross-sectional survey. PARTICIPANTS: A total of 197 registrants from three international cleft/craniofacial meetings. INTERVENTIONS: Participants were sent a web-based questionnaire concerning cleft classification systems. MAIN OUTCOME MEASURES: Frequency of commonly used classification systems, their perceived indications and limitations. RESULTS: A total of 197 respondents from 166 different centers completed the questionnaire. Healthcare professionals from all disciplines responded, with the most frequent respondents being plastic surgeons (38.1%), maxillofacial surgeons (28.4%) and orthodontists (23.9%). Eighteen different classification systems were in use. The most frequently used systems were the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (35.5%), LAHSHAL (34.0%), and Veau (32.5%) classification systems. Most respondents (32.5%) indicated that anatomical and morphological characteristics are essential components of a classification system. However, respondents indicated that their current classification systems lacked sufficient description of cleft extension and severity. CONCLUSIONS: Great variety in the use of classification systems exists among craniofacial specialists internationally. The results recommend the usage of the LAHSHAL classification of OFCs, due to its comprehensiveness, relatively high implementation rate globally, convenience of usage and complementarity with the ICD-10 system. Moreover, it can overcome deficiencies inextricably linked to ICD-10, such as incapacity to describe laterality and clefts of the alveolus. More international exposure to the merits of using the LAHSHAL classification system would be highly recommended.

HOW PRO'S CAN CONTRIBUTE TO WHAT MATTERS MOST TO PATIENTS WITH OROFACIAL CLEFTS.

An orofacial cleft (OC) is a congenital cleft that may affect the lip, alveolus, hard and soft palate. An OC impacts the individuals' appearance, psychosocial well-being and causes functional problems including feeding, dentition, growth of jaws, hearing and speech. The treatment of an orofacial cleft usually reaches from birth until 22 years of age or later. To understand and listen in an objective manner, OC specific Patient reported Outcome (PRO) and experience (PRE) measures are imperative. In patients with OCs many shared decision making moments exist from birth until adulthood. The aim is to understand what knowledge exists on PROs and PREs in patients with OCs, to formulate challenges to improve care to OC patients and how research on OCs needs to adapt. PROs and PREs need to be tailored to the individual with an OC. A framework with specific OC key domains including appearance, facial function and Health related Quality of Life exists. The current framework does not include the social network around the OC patients yet. However attention should be put on including family and community support into the framework. Also at an individual level more attention should be paid to enhancing experiences compared to impeding experiences. To create a better understanding traditional indicators and outcomes are combined with PROMs in a structured way. Challenges were identified that seek to improve our complete set of (PRO and PRE) instruments to provide better care to the individual with an OC and provide a voice so that good shared decision making is enabled. Thereby the individual with an OC is further empowered.

Oral health-related quality of life before, during, and after orthodontic-orthognathic treatment: a systematic review and meta-analysis.

OBJECTIVES: The effect of combined orthodontic-orthognathic treatment was estimated, specifically the impact of pre-surgical orthodontic treatment, on oral health-related quality of life (OHRQoL). MATERIALS AND METHODS: The research question was formulated using the PICO method. The search was carried out in MEDLINE via PubMed, CINAHL, psychINFO, Embase, and Cochrane (until February 3, 2020). Inclusion criteria were patients aged ≥ 17 years who underwent combined orthodontic-surgical treatment, quality of life assessment, and study design of randomized controlled trial, controlled clinical trial, prospective cohort study, observational study, intervention study, or cross-sectional study. The ROBINS-1 tool was used to assess the risk of bias within studies. A random effects meta-analysis was conducted when appropriate. The quality of evidence was assessed using the GRADE approach. RESULTS: Six studies were analyzed. The OHIP-14 and/or OQLQ-22 questionnaires were used to measure the OHRQoL. All six studies had a serious risk of bias. Two studies (87 participants) were included in a meta-analysis showing improvement of OHRQoL when comparing before and after treatment were compared (mean 14.85 scale points, 95% confidence interval 10.36;19.35). CONCLUSIONS: Studies indicate a decrease in OHRQoL during the pre-surgical orthodontic treatment phase but improvement after orthodontic-orthognathic treatment. Data substantiating these results are limited, and the quality of evidence is low. Further research is needed to assess the impact of pre-surgical orthodontic treatment on the OHRQoL in an orthognathic trajectory. CLINICAL RELEVANCE: Patients should be well informed about the effect facial/esthetic changes may have on their OHRQoL during sequential phases of orthodontic-orthognathic treatment.

Treatment Outcome in Bilateral Cleft lip and Palate Patients Evaluated With the Huddart-Bodenham Scoring System and the Bilateral Cleft lip and Palate Yardstick: A Systematic Review.

OBJECTIVES: To assess treatment outcome (transversal and sagittal dental arch relationships) and its determinants in complete bilateral cleft lip and palate (BCLP) evaluated with the modified Huddart-Bodenham scoring system and the BCLP Yardstick. MATERIALS AND METHODS: Multiple electronic databases were searched without time limitation. Randomized clinical trials, cohort and case control studies using BCLP Yardstick and/or modified Huddart-Bodenham system to judge treatment outcome of patients with BCLP were included. The Risk of Bias in Nonrandomized Studies of Interventions tool and Grading of Recommendations, Assessment, Development, and Evaluation was used. RESULTS: Of the 528 studies identified by the electronic search, only eight retrospective studies met the inclusion criteria and were included. A total of 12 cleft centers were represented. All treatment protocols differed and background information was underreported. The results for the BCLP yardstick showed that all except the centers in New Zealand had a mean score lower than 3, indicating good treatment results. However, these studies had a moderate to high risk of bias. The modified Huddart-Bodenham scores were negative in all studies. No further meta-analysis was done due to heterogeneity and high risk of bias. The quality of evidence was graded as very low. CONCLUSION: Results for the dental arch relationship of studies in complete BCLP and possible determinants were not synthesized due to very low quality of evidence. Clinical research for patients with BCLP should focus on sound methodological designs to enable evidence-based decision making to improve treatment for patients with BCLP and thereby hopefully their quality of life.

Evaluation of dental maturity in Muenke syndrome, Saethre-Chotzen syndrome, and TCF12-related craniosynostosis.

OBJECTIVES: To determine whether dental maturity (dental development) was delayed in patients with Muenke syndrome, Saethre-Chotzen syndrome, and TCF12-related craniosynostosis, compared with a Dutch control group without syndromes. MATERIALS AND METHODS: This study included 60 patients (38 patients with Muenke syndrome, 17 patients with Saethre-Chotzen syndrome, and 5 with TCF12-related craniosynostosis), aged 5.8-16.8 years that were treated at the Department of Oral Maxillofacial Surgery, Special Dental Care, and Orthodontics, in Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, the Netherlands. Dental age was calculated according to Demirjian's index of dental maturity. The control group included 451 children without a syndrome. RESULTS: Compared with the control group, dental development was delayed by an average of one year in 5- to 8-year-old patients with Muenke syndrome (P = 0.007) and in 8- to 10-year-old patients with Saethre-Chotzen syndrome (P = 0.044), but not in patients with TCF12-related craniosynostosis. CONCLUSIONS: Our results indicated that dental development was delayed by one year, on average, in patients with Muenke syndrome and Saethre-Chotzen syndrome, compared with a Dutch control group without syndromes. IMPLICATIONS: Our findings have improved the understanding of dental development in patients with Muenke and Saethre-Chotzen syndrome. These results can provide guidance on whether the orthodontist needs to consider growth disturbances related to dental development.

Highly variable rate of orthodontic tooth movement measured by a novel 3D method correlates with gingival inflammation.

OBJECTIVES: Individual orthodontic treatment duration is hard to predict. Individual biological factors are amongst factors influencing individual rate of orthodontically induced tooth movement (OTM). The study aim is to determine the rate of OTM by a novel 3D method and investigate parameters that may predict the rate of tooth movement. MATERIALS AND METHODS: In this prospective cohort study, rate of OTM was determined from 90 three-dimensional intra-oral scans in 15 patients (aged 12-15) undergoing orthodontic treatment. For each patient, intra-oral scans were taken every week for up to 6 weeks (T0-T5). The teeth were segmented from the scans and the scans were superimposed on the palatal rugae. The rate of OTM was calculated for each tooth. Other parameters were gingival inflammation, contact-point displacement and the biological markers, matrix metalloproteinases (MMP), MMP-9 and MMP-2 in gingival crevicular fluid (GCF). RESULTS: Our study showed a high variation in the rate of OTM, varying from 0.15 to 1.24 mm/week. Teeth in the anterior segment tended to move more compared with the posterior segment. The contact point displacement and gingival inflammation varied greatly amongst the patients. The MMPs measured did not correlate with tooth movement. However, the gingival inflammation index showed a significant correlation with OTM. Future studies should include other biological markers related to bone-remodeling. CONCLUSION: This novel and efficient 3D method is suitable for measuring OTM and showed large individual variation in rate of OTM. CLINICAL RELEVANCE: Patients show different rates of OTM. The rate of OTM in an individual patient can provide guidance in timing of follow-up appointments.

Tissue engineering strategies combining molecular targets against inflammation and fibrosis, and umbilical cord blood stem cells to improve hampered muscle and skin regeneration following cleft repair.

Cleft lip with or without cleft palate is a congenital deformity that occurs in about 1 of 700 newborns, affecting the dentition, bone, skin, muscles and mucosa in the orofacial region. A cleft can give rise to problems with maxillofacial growth, dental development, speech, and eating, and can also cause hearing impairment. Surgical repair of the lip may lead to impaired regeneration of muscle and skin, fibrosis, and scar formation. This may result in hampered facial growth and dental development affecting oral function and lip and nose esthetics. Therefore, secondary surgery to correct the scar is often indicated. We will discuss the molecular and cellular pathways involved in facial and lip myogenesis, muscle anatomy in the normal and cleft lip, and complications following surgery. The aim of this review is to outline a novel molecular and cellular strategy to improve musculature and skin regeneration and to reduce scar formation following cleft repair. Orofacial clefting can be diagnosed in the fetus through prenatal ultrasound screening and allows planning for the harvesting of umbilical cord blood stem cells upon birth. Tissue engineering techniques using these cord blood stem cells and molecular targeting of inflammation and fibrosis during surgery may promote tissue regeneration. We expect that this novel strategy improves both muscle and skin regeneration, resulting in better function and esthetics after cleft repair.

Consortium-based genome-wide meta-analysis for childhood dental caries traits.

Prior studies suggest dental caries traits in children and adolescents are partially heritable, but there has been no large-scale consortium genome-wide association study (GWAS) to date. We therefore performed GWAS for caries in participants aged 2.5-18.0 years from nine contributing centres. Phenotype definitions were created for the presence or absence of treated or untreated caries, stratified by primary and permanent dentition. All studies tested for association between caries and genotype dosage and the results were combined using fixed-effects meta-analysis. Analysis included up to 19 003 individuals (7530 affected) for primary teeth and 13 353 individuals (5875 affected) for permanent teeth. Evidence for association with caries status was observed at rs1594318-C for primary teeth [intronic within ALLC, odds ratio (OR) 0.85, effect allele frequency (EAF) 0.60, P 4.13e-8] and rs7738851-A (intronic within NEDD9, OR 1.28, EAF 0.85, P 1.63e-8) for permanent teeth. Consortium-wide estimated heritability of caries was low [h2 of 1% (95% CI: 0%: 7%) and 6% (95% CI 0%: 13%) for primary and permanent dentitions, respectively] compared with corresponding within-study estimates [h2 of 28% (95% CI: 9%: 48%) and 17% (95% CI: 2%: 31%)] or previously published estimates. This study was designed to identify common genetic variants with modest effects which are consistent across different populations. We found few single variants associated with caries status under these assumptions. Phenotypic heterogeneity between cohorts and limited statistical power will have contributed; these findings could also reflect complexity not captured by our study design, such as genetic effects which are conditional on environmental exposure.

Three-dimensional characterization of mandibular asymmetry in craniofacial microsomia.

OBJECTIVES: This study aimed to investigate the three-dimensional (3D) mandibular asymmetry in craniofacial microsomia (CFM) and its association with the Pruzansky-Kaban classification system. MATERIALS AND METHODS: Cone-beam computed tomography images of 48 adult CFM cases were collected. The asymmetry of the mandibular body and ramus was analyzed with 3D landmarks. The mirrored mandibular model was registered on the original model, yielding a color-coded distance map and an average distance (i.e., asymmetry score) to quantify the overall mandibular asymmetry. RESULTS: The lengths of the mandibular body and ramus were significantly shorter on the affected than the contralateral side (p < 0.001). The ANB (p = 0.009), body and ramal lengths (both p < 0.001), and body and ramal length asymmetry (both p < 0.05) were significantly different between mild (types I/IIA) and severe (types IIB/III) cases. The mandibular asymmetry score correlated with mandibular body length asymmetry (r = 0.296, p = 0.046). CFM mandibles showed high variability in shape asymmetry. CONCLUSIONS: CFM patients showed distinct body and ramal length asymmetries. In severe cases, mandibles were smaller, more retruded, and more asymmetric in length. The mandibular shape asymmetry was highly variable regardless of the Pruzansky-Kaban types, being a determinant in the extent of overall mandibular asymmetry. CLINICAL RELEVANCE: The 3D morphologic analysis provides better insights into real mandibular asymmetry. Although the Pruzansky-Kaban classification was applied, high individual variability of the mandibular morphology still existed within the types. Therefore, individualized analyses and treatment plans for CFM patients are highly recommended.

Impact of orthodontic treatment need and deviant occlusal traits on oral health-related quality of life in children: A cross-sectional study in the Generation R cohort.

INTRODUCTION: Many studies have investigated the impact of orthodontic treatment need (OTN) on children's oral health-related quality of life (OHRQOL). However, few studies have explored the impact of deviant occlusal traits on OHRQOL regarding the severity of OTN. This cross-sectional study aims to address this gap in the literature. METHODS: This study was conducted within the Generation R Study, a population-based prospective cohort study. We assessed OTN with the Index of Orthodontic Treatment Need and OHRQOL with a parental short-form of the Child Oral Health Impact Profile in 3048 children at a median age of 9.74 years (9.5-10.0). We also further assessed individual malocclusion traits in a subsample of 2714 children. We investigated the association between OTN, malocclusion traits, and OHRQOL using multiple regression analysis with weighted least squares. RESULTS: Children with definite (adjusted effect estimate = -0.81; 95% confidence interval -1.12 to -0.50) or borderline (adjusted effect estimate = -0.34; 95% confidence interval -0.61 to -0.08) OTN experienced significant decreases in their OHRQOL than those with no need. An impacted tooth, increased overjet, or crowding had significant negative impacts on children's OHRQOL. Children with an overjet experienced negative impacts on OHRQOL even when orthodontic treatment was not necessary. CONCLUSIONS: Progressively greater OTN has increasingly negative impacts on parent's perception of children's OHRQOL. In particular, children presenting with large overjets and impacted teeth have lower OHRQOL. These perspectives add to better patient-clinician communication and understanding of patient expectations around OTN, which may potentially lead to improvements in quality of care from the patient perspective.

Dental development and craniofacial morphology in school-age children.

INTRODUCTION: The growth of the craniofacial complex is important for establishing a balanced relationship among the teeth, jaws, and other facial structures. However, there is still a lack of information about craniofacial parameters that are affected by the rate of dental development. The aim of this study was to investigate the association between dental development and craniofacial morphology in school-age children. METHODS: This study was embedded in the Generation R Study, Rotterdam, The Netherlands. In 3,896 children aged 8 to 11 years, dental development was assessed from panoramic radiographs and craniofacial morphology was assessed by combining cephalometric parameters into 9 uncorrelated principal components, each representing a distinct skeletal or dental craniofacial pattern. The statistical analysis was performed using linear and nonlinear regression model. RESULTS: Dental development was positively associated with the bimaxillary growth (ß = 0.04; 95% CI 0.01 to 0.08). Children with above-average dental development had a tendency toward Class II jaw relationship (ß = -0.08; 95% CI -0.13 to -0.04). Regarding dental parameters, the proclination increased for incisors and lips with advanced dental development (ß = 0.15 [95% CI 0.10 to 0.19] and ß = 0.13 [95% CI 0.09 to 0.17], respectively), but the incisor proclination remained more pronounced in children that had above-average dental development. CONCLUSIONS: The findings of this large population-based study show that dental development is associated with specific dental and skeletal cephalometric characteristics in school-age children. Further longitudinal studies are necessary to confirm the observed effects over time.

The role of accelerated dental development on the occurrence of aberrant dental traits that indicate malocclusion.

BACKGROUND: Timing of dental development might help orthodontists to optimize initiation of treatment and to prevent and intercept dental misalignment. This study examines the association between timing of dental development and aberrant dental traits such as crowding, impaction, and hypodontia. METHODS: This study was performed using 4446 ten-year-old children from a multiethnic birth cohort, the Generation R Study. Dental development was defined using the Demirjian method. Crowding, impaction, and hypodontia were ascertained from 2D and 3D pictures and radiographs. We built three series of logistic regression models to test the associations of dental age with crowding, impaction, and hypodontia. Similar models were built to investigate the associations of the developmental stages of each left mandibular tooth with crowding, impaction, and hypodontia. RESULTS: Inverse associations were found between every 1-year increase in dental age and the presence of crowding [odds ratio (OR) = 0.84, 95% confidence interval (CI): 0.79, 0.89], impaction of teeth (OR = 0.66, 95% CI: 0.52, 0.84), and hypodontia (OR = 0.52, 95% CI: 0.47, 0.56). Lower developmental stages of the second premolar were associated with the presence of crowding (OR = 0.90, 95% CI: 0.83, 0.98). Lower developmental stages of the second premolar (OR = 0.88, 95% CI: 0.79, 0.98), first molar (OR = 0.76, 95% CI: 0.65, 0.90), and the second molar (OR = 0.83, 95% CI: 0.73, 0.94) were associated with the presence of tooth impaction. Lower developmental stages of all mandibular teeth except the central incisor were associated with hypodontia (P < 0.05). CONCLUSION: Accelerated dental development is associated with lower occurrence of crowding, impaction, and hypodontia.

Ancestry and dental development: A geographic and genetic perspective.

OBJECTIVE: In this study, we investigated the influence of ancestry on dental development in the Generation R Study. METHODS: Information on geographic ancestry was available in 3,600 children (1,810 boys and 1,790 girls, mean age 9.81 ± 0.35 years) and information about genetic ancestry was available in 2,786 children (1,387 boys and 1,399 girls, mean age 9.82 ± 0.34 years). Dental development was assessed in all children using the Demirjian method. The associations of geographic ancestry (Cape Verdean, Moroccan, Turkish, Dutch Antillean, Surinamese Creole and Surinamese Hindustani vs Dutch as the reference group) and genetic content of ancestry (European, African or Asian) with dental development was analyzed using linear regression models. RESULTS: In a geographic perspective of ancestry, Moroccan (ß = 0.18; 95% CI: 0.07, 0.28), Turkish (ß = 0.22; 95% CI: 0.12, 0.32), Dutch Antillean (ß = 0.27; 95% CI: 0.12, 0.41), and Surinamese Creole (ß = 0.16; 95% CI: 0.03, 0.30) preceded Dutch children in dental development. Moreover, in a genetic perspective of ancestry, a higher proportion of European ancestry was associated with decelerated dental development (ß = -0.32; 95% CI: -.44, -.20). In contrast, a higher proportion of African ancestry (ß = 0.29; 95% CI: 0.16, 0.43) and a higher proportion of Asian ancestry (ß = 0.28; 95% CI: 0.09, 0.48) were associated with accelerated dental development. When investigating only European children, these effect estimates increased to twice as large in absolute value. CONCLUSION: Based on a geographic and genetic perspective, differences in dental development exist in a population of heterogeneous ancestry and should be considered when describing the physiological growth in children.

Stress in Parents of a Child with Hemifacial Microsomia: The Role of Child Characteristics and Parental Coping Strategies.

OBJECTIVE: Examine stress levels of parents of children with hemifacial microsomia (HFM) and the relationship of parental stress to child characteristics and cognitive coping strategies. DESIGN: Prospective cross-sectional study. PARTICIPANTS AND SETTING: Parents with a child (age 3-19 years) with HFM (N = 31) were recruited through the Department of Orthodontics and the Craniofacial Center, Sophia-Erasmus Medical Center, Rotterdam, The Netherlands. Intervention and Outcome Measures: The adapted and shortened Dutch version of the parental stress index (NOSI-K) was used to measure parental stress, and the cognitive emotion-regulation questionnaire was used to measure cognitive coping strategies. Pearson correlations and a multiple regression analysis were performed. RESULTS: The hierarchical multiple regression analysis showed associations between increased parental stress and learning difficulties and use of acceptance as a coping strategy. This suggests that problems other than the characteristic visual appearance of the child's face in HFM have a greater influence on parental stress. CONCLUSIONS: Learning difficulties of the child with HFM and parental acceptance affect stress in parents with a child with HFM the most and are important in the search for a targeted tailoring of intervention for parents with high levels of parental stress.

Subphenotyping and Classification of Cleft Lip and Alveolus in Adult Unoperated Patients: A New Embryological Approach.

OBJECTIVE: Previously, a new embryological classification was introduced subdividing oral clefts into fusion and/or differentiation defects. This subdivision was used to classify all subphenotypes of cleft lip with or without alveolus (CL±A). Subsequently, it was investigated whether further morphological grading of incomplete CLs is clinically relevant, and which alveolar part is deficient in fusion/differentiation defects. DESIGN: Observational cohort study. SETTING: Three hundred fifty adult unoperated Indonesian cleft patients presented themselves for operation. Cephalograms, dental casts, and intraoral and extraoral photographs-eligible for the present study-were used to determine morphological severity of CL±A. PATIENTS: Patients with unilateral or bilateral clefts of the primary palate only were included. MAIN OUTCOME MEASURES: Clefts were classified-according to developmental mechanisms and timing in embryogenesis-as fusion and/or differentiation defects. Grades of incomplete CLs were related to the severity of alveolar clefts (CAs) and hypoplasia, and permanent dentition was used to investigate which alveolar part is deficient in fusion/differentiation defects. RESULTS: One hundred eight adult patients were included. All subphenotypes-96 unilateral and 12 bilateral clefts-could be classified into differentiation (79%), fusion (17%), fusion-differentiation (2%), or fusion and differentiation (2%) defects. The various grades of incomplete CLs were related to associated CAs and hypoplasia, and all alveolar deformities were located in the premaxillae. CONCLUSIONS: This study showed that all CL±A including the Simonart bands can be classified, that further morphological grading of incomplete CLs is clinically relevant, and that the premaxilla forms the deficient part in alveolar deformities.

Influence of self-esteem on perceived orthodontic treatment need and oral health-related quality of life in children: the Generation R Study.

Background: Self-esteem (SE) is suggested to influence the relationship between orthodontic treatment need and oral health-related quality of life (OHRQoL), but evidence lacks. The aim of the present study was to investigate SE in the relationship between subjective orthodontic need and OHRQoL in children. Methods: This cross-sectional study was embedded in the Generation R Study, a multi-ethnic population-based cohort. In total, 3796 10-year old children participated in the present study. OHRQoL, measured with the Child Oral Health Impact Profile-ortho, and subjective orthodontic need were assessed within parental questionnaires. SE was measured with a modified version of the Harter's self-perception profile rated by the children. The role of SE in the association between SOT and OHRQoL was evaluated with linear regression models. Furthermore, the difference in this association between children with high and low SE was investigated. Results: Higher subjective orthodontic need was associated with lower OHRQoL scores (borderline: ß [95% CI] = -0.55 [-0.77, -0.33]; definite: -1.65 [-1.87, -1.54]). Children with lower SE scores showed a stronger relationship between borderline and definite subjective orthodontic need with OHRQoL (ß [95% CI] = -0.56 [-0.81, -0.31] respectively -1.68 [-1.94, -1.42]) than children with higher SE scores did (ß [95% CI] = -0.51 [-0.97, -0.04] respectively -1.43 [-1.90, -0.95]). Conclusion: The relationship between subjective orthodontic need and OHRQoL is not based on the SE of children. However, SE modifies the relationship between subjective orthodontic need and OHRQoL. Work still needs to be done to find an explanation for the effect modification by SE in the relationship between subjective health perceptions and OHRQoL.

Airway volume analysis: is there a correlation between two and three-dimensions?

Objectives: No consensus exists on the assessment of airway in CBCT scans. Two-dimensional measures remain the standard in the cephalometric analysis. This research aimed to evaluate linear and area measurements in two-dimensional views from specific airway regions of interest and compare these to the correspondent volume in CBCT exams. Materials and Methods: 250-selected CBCT scans were retrospectively analyzed. A trained and calibrated examiner performed the linear, area and volume measurements in specific sites for nasal cavity, nasopharynx and oropharynx compartments. Dolphin Software was used for the analysis. The correlations were performed using Pearson coefficient. Results: The highest positive correlations were observed in the nasopharynx and oropharynx sagittal areas and the most constricted area in the oropharynx. Nasopharynx linear measures and nasopharynx coronal area did not present correlation with whole volume. Two-dimensional measurements in the soft palate (width and sagittal area) showed very low positive correlations. Although nasal cavity presented highest volume means, changes in oropharynx contributed more to variations in total volume, compared with the other two sections. Conclusion: Airway sagittal areas, as well as the most constricted axial area in oropharynx remains a useful guide to correlate with airway volume in two-dimensional images.