Luca Contardo

A systematic review of therapeutical approaches in bisphosphonates-related osteonecrosis of the jaw (BRONJ)

OBJECTIVES The clinical management of bisphosphonate-related osteonecrosis of the jaw (BRONJ) remains controversial. Since universally accepted guidelines have not been released yet, clinicians usually chose the type of treatment according to position papers based on expert opinion, or on empirical experience. The aim of this systematic review is to identify different therapeutical approaches for BRONJ that have been described in literature and to describe their effectiveness. MATERIALS AND METHODS A Medline via Pubmed and Scopus database literature search was conducted and all publications fulfilling the inclusion and exclusion criteria were included in eligibility assessment. The full texts of 146 retrieved articles were then screened and 40 studies were included in the quality assessment process. RESULTS After quality assessment, 22 full text articles were selected for the final review. 14 articles out of 22 were screened for stage-related outcomes. The overall outcome results and results for every disease stage were the highest when patients were treated with extensive surgery or extensive laser assisted surgery.

A novel animal model to study non‐spontaneous bisphosphonates osteonecrosis of jaw

The aim of this study was to evaluate a novel animal model of bisphosphonates-associated osteonecrosis, which realistically recapitulates the same pathological human condition. Five Wistar rats were given intravenous zoledronic acid 0.04 mg once a week for 5 weeks. After 2 weeks, the animals underwent the extraction of an upper molar, producing a 4 mm-diameter bone defect on the same site. After 7 weeks from the extraction, the animals were clinically examined and a bone scintigraphy was carried out. After an additional week, the rats were killed and both Computerized Tomography and histological analysis were performed. Five rats, not treated with zoledronic acid and exposed to the same surgical treatment, were used as controls. At 7 weeks after the extraction, all the rats treated with zoledronic acid showed expansion of the defect and bone exposure. These features were confirmed by bone scintigraphy. The rats of the control group demonstrated epithelialization of the bone defect and a normal uptake of the contrast medium during the scan. The Computerized Tomography scan disclosed irregularity of the cortical margin and bone destruction, which were not evident in the control group. On microscopy, the samples showed necrotic bone, loss of osteocytes and peripheral resorption without inflammatory infiltrate, while the controls showed normal bone healing. The rat treated with zoledronic acid can be considered a novel, reliable and reproducible animal model to understand better the pathophysiology of osteonecrosis of the jaw and to develop a therapeutic approach.

KPG index versus OPG measurements: a comparison between 3D and 2D methods in predicting treatment duration and difficulty level for patients with impacted maxillary canines.

Aim. The aim of this study was to test the agreement between orthopantomography (OPG) based 2D measurements and the KPG index, a new index based on 3D Cone Beam Computed Tomography (CBCT) images, in predicting orthodontic treatment duration and difficulty level of impacted maxillary canines. Materials and Methods. OPG and CBCT images of 105 impacted canines were independently scored by three orthodontists at t 0 and after 1 month (t 1), using the KPG index and the following 2D methods: distance from cusp tip and occlusal plane, cusp tip position in relation to the lateral incisor, and canine inclination. Pearsons coefficients were used to evaluate the degree of agreement and the χ 2 with Yates correction test was used to assess the independence between them. Results. Inter- and intrarater reliability were higher with KPG compared to 2D methods. Pearsons coefficients showed a statistically significant association between all the indexes, while the χ 2 with Yates correction test resulted in a statistically significant rejection of independency only for one 2D index. Conclusions. 2D indexes for predicting impacted maxillary canines treatment duration and difficulty sometimes are discordant; a 3D index like the KPG index could be useful in solving these conflicts.

Diagnostic performance of dental maturity for identification of skeletal maturation phase

The objective of this study is to analyse the diagnostic performance of the circumpubertal dental maturation phases for the identification of individual-specific skeletal maturation phases. A total of 354 healthy subjects, 208 females and 146 males (mean age, 11.1 ± 2.4 years; range, 6.8-17.1 years), were enrolled in the study. Dental maturity was assessed through the calcification stages from panoramic radiographs of the mandibular canine, the first and second premolars, and the second molar. Determination of skeletal maturity was according to the cervical vertebra maturation (CVM) method on lateral cephalograms. Diagnostic performances were evaluated according to the dental maturation stages for each tooth for the identification of the CVM stages and growth phases (as pre-pubertal, pubertal, and post-pubertal) using positive likelihood ratios (LHRs). A positive LHR threshold of 10 or more was considered for satisfactory reliability of any dental maturation stage for the identification of any of the CVM stages or growth phases. The positive LHRs were generally less than 2.0, with a few exceptions. These four teeth showed positive LHRs greater than 10 only for the identification of the pre-pubertal growth phase, with values from 10.8 for the second molar (stage E) to 39.3 for the first premolar (stage E). Dental maturation assessment is only useful for diagnosis of the pre-pubertal growth phase, and thus, precise information in relation to the timing of the onset of the growth spurt is not provided by these indices.

Dental malocclusion and body posture in young subjects: a multiple regression study

OBJECTIVES: Controversial results have been reported on potential correlations between the stomatognathic system and body posture. We investigated whether malocclusal traits correlate with body posture alterations in young subjects to determine possible clinical applications. METHODS: A total of 122 subjects, including 86 males and 36 females (age range of 10.8–16.3 years), were enrolled. All subjects tested negative for temporomandibular disorders or other conditions affecting the stomatognathic systems, except malocclusion. A dental occlusion assessment included phase of dentition, molar class, overjet, overbite, anterior and posterior crossbite, scissorbite, mandibular crowding and dental midline deviation. In addition, body posture was recorded through static posturography using a vertical force platform. Recordings were performed under two conditions, namely, i) mandibular rest position (RP) and ii) dental intercuspidal position (ICP). Posturographic parameters included the projected sway area and velocity and the antero-posterior and right-left load differences. Multiple regression models were run for both recording conditions to evaluate associations between each malocclusal trait and posturographic parameters. RESULTS: All of the posturographic parameters had large variability and were very similar between the two recording conditions. Moreover, a limited number of weakly significant correlations were observed, mainly for overbite and dentition phase, when using multivariate models. CONCLUSION: Our current findings, particularly with regard to the use of posturography as a diagnostic aid for subjects affected by dental malocclusion, do not support existence of clinically relevant correlations between malocclusal traits and body posture.

Treatment Effects of Removable Functional Appliances in Pre-Pubertal and Pubertal Class II Patients: A Systematic Review and Meta-Analysis of Controlled Studies

Background Treatment effects of removable functional appliances in Class II malocclusion patients according to the pre-pubertal or pubertal growth phase has yet to be clarified. Objectives To assess and compare skeletal and dentoalveolar effects of removable functional appliances in Class II malocclusion treatment between pre-pubertal and pubertal patients. Search methods Literature survey using the Medline, SCOPUS, LILACS and SciELO databases, the Cochrane Library from inception to May 31, 2015. A manual search was also performed. Selection criteria Randomised (RCTs) or controlled clinical trials with a matched untreated control group. No restrictions were set regarding the type of removable appliance whenever used alone. Data collection and analysis For the meta-analysis, cephalometric parameters on the supplementary mandibular growth were the main outcomes, with other cephalometric parameters considered as secondary outcomes. Risk of bias in individual and across studies were evaluated along with sensitivity analysis for low quality studies. Mean differences and 95% confidence intervals for annualised changes were computed according to a random model. Differences between pre-pubertal and pubertal patients were assessed by subgroup analyses. GRADE assessment was performed for the main outcomes. Results Twelve articles (but only 3 RCTs) were included accounting for 8 pre-pubertal and 7 pubertal groups. Overall supplementary total mandibular length and mandibular ramus height were 0.95 mm (0.38, 1.51) and 0.00 mm (-0.52, 0.53) for pre-pubertal patients and 2.91 mm (2.04, 3.79) and 2.18 mm (1.51, 2.86) for pubertal patients, respectively. The subgroup difference was significant for both parameters (p<0.001). No maxillary growth restrain or increase in facial divergence was seen in either subgroup. The GRADE assessment was low for the pre-pubertal patients, and generally moderate for the pubertal patients. Conclusions Taking into account the limited quality and heterogeneity of the included studies, functional treatment by removable appliances may be effective in treating Class II malocclusion with clinically relevant skeletal effects if performed during the pubertal growth phase.

Dentition phase and chronological age in relation to gingival crevicular fluid alkaline phosphatase activity in growing subjects.

OBJECTIVE Identification of skeletal maturation phases is of primary importance in terms of individual responsiveness to nearly all dentofacial orthopaedic treatments. In this regard, dentition phase and chronological age are still widely used to define the timing of and responsiveness to orthodontic treatments. Recently, gingival crevicular fluid (GCF) alkaline phosphatase (ALP) activity has been shown to be a reliable biomarker of skeletal maturation in growing subjects. Here, for the first time, circumpubertal dentition phases and chronological age were evaluated for correlations with GCF ALP activity, as a biomarker of skeletal maturation. MATERIALS AND METHODS Eighty-five healthy growing subjects (51 females, 34 males; mean age, 11.7±2.3 years) were enrolled into this double-blind, prospective, cross-sectional-design study. Samples of GCF were collected from each subject at the mesial and distal sites of both of the central incisors, at the maxillary and mandibular arches. Their dentition phases were recorded as intermediate mixed, late mixed, or permanent. GCF ALP enzymatic activity was determined spectrophotometrically. RESULTS The dentition phases showed median GCF ALP activities from 42.0 to 67.5 mU/sample. Although these were slightly greater for the permanent dentition, no significant differences were seen. Also, the chronological age did not correlate significantly with GCF ALP activity, and no significant differences were seen between maxillary and mandibular sites in any of the comparisons. CONCLUSIONS Assessment for treatment timing of dentofacial disharmonies in individual patients that require monitoring of their skeletal maturation phases should not rely on their circumpubertal dentition phase and chronological age.

Treatment effects of fixed functional appliances alone or in combination with multibracket appliances: A systematic review and meta-analysis.

OBJECTIVE To assess skeletal and dentoalveolar effects of fixed functional appliances, alone or in combination with multibracket appliances (comprehensive treatment), on Class II malocclusion in pubertal and postpubertal patients. MATERIALS AND METHODS Literature survey was conducted using the Medline, SCOPUS, LILACS, and SciELO databases and The Cochrane Library, and through a manual search. The studies retrieved had to have a matched untreated control group. No restrictions were set regarding the type of fixed appliance, treatment length, or to the cephalometric analysis used. Data extraction was mostly predefined at the protocol stage by two authors. Supplementary mandibular elongation was used for the meta-analysis. RESULTS Twelve articles qualified for the final analysis of which eight articles were on pubertal patients and four were on postpubertal patients. Overall supplementary total mandibular elongations as mean (95% confidence interval) were 1.95 mm (1.47 to 2.44) and 2.22 mm (1.63 to 2.82) among pubertal patients and -1.73 mm (-2.60 to -0.86) and 0.44 mm (-0.78 to 1.66) among postpubertal patients, for the functional and comprehensive treatments, respectively. For pubertal subjects, maxillary growth restraint was also reported. Nevertheless, skeletal effects alone would not account for the whole Class II correction even in pubertal subjects with dentoalveolar effects always present. CONCLUSIONS Fixed functional treatment is effective in treating Class II malocclusion with skeletal effects when performed during the pubertal growth phase, very few data are available on postpubertal patients.

Visual assessment of the cervical vertebral maturation stages: A study of diagnostic accuracy and repeatability

OBJECTIVE To evaluate the diagnostic accuracy and repeatability of the visual assessment of the cervical vertebral maturation (CVM) stages. MATERIALS AND METHODS Ten operators underwent training sessions in visual assessment of CVM staging. Subsequently, they were asked to stage 72 cases equally divided into the six stages. Such assessment was repeated twice in two sessions (T1 and T2) 4 weeks apart. A reference standard for each case was created according to a cephalometric analysis of both the concavities and shapes of the cervical vertebrae. RESULTS The overall agreement with the reference standard was about 68% for both sessions and 76.9% for intrarater repeatability. The overall kappa coefficients with the reference standard were up to 0.86 for both sessions, and 0.88 for intrarater repeatability. Overall, disagreements one stage and twp stage apart were 23.5% (T1) and 5.1% (T2), respectively. Sensitivity ranged from 53.3% for CS5 (T1) to 99.9% for CS1 (T2), positive predictive values ranged from 52.4% for CS5 (T2) to 94.3% for CS6 (T1), and accuracy ranged from 83.6% for CS4 (T2) to 94.9% for CS1 (T1). CONCLUSIONS Visual assessment of the CVM stages is accurate and repeatable to a satisfactory level. About one in three cases remain misclassified; disagreement is generally limited to one stage and is mostly seen in stages 4 and 5.

Do malocclusion and Helkimo Index ≥5 correlate with body posture?

Whether there are correlations between the stomatognathic system and body posture remains controversial. Here, we have investigated whether malocclusal traits and having a Helkimo Index ≥ 5 show detectable correlations with body-posture alterations in children and young adults. A total of 1178 11- to 19-year-old subjects were divided into four groups: (i) controls; (ii) malocclusion; (iii) Helkimo Index ≥ 5 and (iv) malocclusion + Helkimo Index ≥ 5. Dental occlusion assessment included the following: overbite, overjet, posterior crossbite, scissorbite, mandibular crowding and dental class. Subsequently, body-posture assessments were performed through static analyses of body inclination and trunk asymmetry, and according to the dynamic Fukuda stepping test. Univariate and multivariate statistical analyses were performed. Although at the univariate level both the trunk asymmetry and Fukuda stepping test showed significant differences among the groups, the multivariate level revealed that age and gender were mostly responsible for this. The only significant correlation that was seen was for the malocclusion + Helkimo Index ≥ 5 group: these subjects had a positive (worse) trunk asymmetry and a negative (better) Fukuda stepping test performance. At the further multivariate analyses of each single malocclusal trait ⁄Helkimo Index ≥ 5 (irrespective of the groups), only an increased overbite showed a statistically significant association with a slightly better Fukuda stepping test performance. Given the small number of significant associations seen and their limited entities, this study does not support the existence of clinically relevant correlations for malocclusal traits and Helkimo Index ≥ 5 with body posture in children and young adults.