M. Ali Darendeliler

Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea A Randomized Controlled Trial

RATIONALE Continuous positive airway pressure (CPAP) and mandibular advancement device (MAD) therapy are commonly used to treat obstructive sleep apnea (OSA). Differences in efficacy and compliance of these treatments are likely to influence improvements in health outcomes. OBJECTIVES To compare health effects after 1 month of optimal CPAP and MAD therapy in OSA. METHODS In this randomized crossover trial, we compared the effects of 1 month each of CPAP and MAD treatment on cardiovascular and neurobehavioral outcomes. MEASUREMENTS AND MAIN RESULTS Cardiovascular (24-h blood pressure, arterial stiffness), neurobehavioral (subjective sleepiness, driving simulator performance), and quality of life (Functional Outcomes of Sleep Questionnaire, Short Form-36) were compared between treatments. Our primary outcome was 24-hour mean arterial pressure. A total of 126 patients with moderate-severe OSA (apnea hypopnea index [AHI], 25.6 [SD 12.3]) were randomly assigned to a treatment order and 108 completed the trial with both devices. CPAP was more efficacious than MAD in reducing AHI (CPAP AHI, 4.5 ± 6.6/h; MAD AHI, 11.1 ± 12.1/h; P < 0.01) but reported compliance was higher on MAD (MAD, 6.50 ± 1.3 h per night vs. CPAP, 5.20 ± 2 h per night; P < 0.00001). The 24-hour mean arterial pressure was not inferior on treatment with MAD compared with CPAP (CPAP-MAD difference, 0.2 mm Hg [95% confidence interval, -0.7 to 1.1]); however, overall, neither treatment improved blood pressure. In contrast, sleepiness, driving simulator performance, and disease-specific quality of life improved on both treatments by similar amounts, although MAD was superior to CPAP for improving four general quality-of-life domains. CONCLUSIONS Important health outcomes were similar after 1 month of optimal MAD and CPAP treatment in patients with moderate-severe OSA. The results may be explained by greater efficacy of CPAP being offset by inferior compliance relative to MAD, resulting in similar effectiveness. Clinical trial registered with https://www.anzctr.org.au (ACTRN 12607000289415).

The Effect of mandibular advancement on upper airway structure in obstructive sleep apnoea

Background The mechanisms by which mandibular advancement splints (MAS) improve obstructive sleep apnoea (OSA) are not well understood. This study aimed to evaluate the mechanism of action of MAS by assessing their effect on upper airway structure in patients with OSA. Methods Patients were recruited from a sleep disorders clinic for treatment with a custom-made MAS. MRI of the upper airway was performed during wakefulness in the supine position, with and without the MAS. Results Sixty-nine patients with OSA were recruited. Treatment with the MAS reduced the apnoea–hypopnoea index (AHI) from 27.0±14.7 events/h to 12.2±12.5 events/h (p<0.001). There was an increase in the total airway volume with mandibular advancement (16.5±0.7 cm3 vs 18.1±0.8 cm3; p<0.01) that occurred predominantly because of an increase in the volume of the velopharynx (5.7±0.3 cm3 vs 6.5±0.3 cm3; p<0.001). This increase in airway calibre was associated with an increase in the lower anterior facial height (6.8±0.1 cm vs 7.5±0.1 cm; p<0.001), reduction in the distance between the hyoid and posterior nasal spine (7.4±0.1 cm vs 7.2±0.1 cm; p<0.001), lateral displacement of the parapharyngeal fat pads away from the airway (right parapharyngeal fat pad 0.17±0.02 cm; left parapharyngeal fat pad 0.22±0.02 cm) and anterior movement of the tongue base muscles (0.33±0.03 cm). Subanalyses in responders and non-responders to MAS treatment showed that the increase in upper airway calibre with mandibular advancement occurred only in responders. Conclusion These results suggest that the mechanism of action of MAS is to increase the volume of the upper airway, predominantly by increasing the volume of the velopharynx, and this increased volume is associated with changes in the surrounding bony and soft tissue structures.

The Adaptive Remodeling of Condylar Cartilage— A Transition from Chondrogenesis to Osteogenesis

Mandibular condylar cartilage is categorized as articular cartilage but markedly distinguishes itself in many biological aspects, such as its embryonic origin, ontogenetic development, post-natal growth mode, and histological structures. The most marked uniqueness of condylar cartilage lies in its capability of adaptive remodeling in response to external stimuli during or after natural growth. The adaptation of condylar cartilage to mandibular forward positioning constitutes the fundamental rationale for orthodontic functional therapy, which partially contributes to the correction of jaw discrepancies by achieving mandibular growth modification. The adaptive remodeling of condylar cartilage proceeds with the biomolecular pathway initiating from chondrogenesis and finalizing with osteogenesis. During condylar adaptation, chondrogenesis is activated when the external stimuli, e.g., condylar repositioning, generate the differentiation of mesenchymal cells in the articular layer of cartilage into chondrocytes, which proliferate and then progressively mature into hypertrophic cells. The expression of regulatory growth factors, which govern and control phenotypic conversions of chondrocytes during chondrogenesis, increases during adaptive remodeling to enhance the transition from chondrogenesis into osteogenesis, a process in which hypertrophic chondrocytes and matrices degrade and are replaced by bone. The transition is also sustained by increased neovascularization, which brings in osteoblasts that finally result in new bone formation beneath the degraded cartilage.

Force Magnitude and Duration Effects on Amount of Tooth Movement and Root Resorption in the Rat Molar

OBJECTIVE To test the hypothesis that there is no difference in the effect of different continuous moderate to very heavy forces on root resorption or amount of tooth movement. MATERIALS AND METHODS In the study, 10, 25, 50 and 100 g mesial force were applied to the maxillary first molars of rat using nickel titanium closed-coil springs for 3 days, 14 days, and 28 days. The molars were extracted and the surface areas of the root resorption craters were measured using scanning electron microscope. The depths of the root resorption craters were measured using a three-dimensional laser scanning microscope. Tooth movement of the maxillary first molar was measured in relation to the maxillary second molar on digitized lateral cephalometric radiographs. RESULTS Three days after force application, the tooth movement was not proportionally related to force magnitude. However, 14 days of force application resulted in significantly more tooth movement in the 10, 25, and 50 g force groups than in the 100 g force group. A force application of 10 g produced significantly more tooth movement at 28 days than all the other three force applications. The largest and deepest resorption craters were observed in the disto-buccal root followed by disto-palatal, middle-buccal, middle-palatal, and mesial root. Root resorption and tooth movement increased over time from 3 to 28 days. As heavier forces were applied, greater root resorption occurred. CONCLUSION The hypothesis is rejected. The light mesially oriented forces, as applied in this study, produced more tooth movement and less root resorption compared with heavier forces.

Mechanical responses to orthodontic loading: A 3-dimensional finite element multi-tooth model

INTRODUCTION The initial mechanical response to orthodontic loading comprises biologic reactions that remain unclear, despite their clinical significance. We used a 3-dimensional finite element analysis to investigate the stress-strain responses of teeth to orthodontic loading. METHODS The model was derived from computed tomography data, with adequate boundary conditions and tissue characterization, with orthodontic hardware to provide a more accurate reflection of events during orthodontic therapy. This study also incorporated the adjacent dentition. Two cases were analyzed: a single-tooth system with a mandibular canine, and a multi-tooth system consisting of the mandibular incisor, the canine, and the first premolar, subjected to orthodontic tipping forces. RESULTS AND CONCLUSIONS The systems experienced elevated distortion strain energies in the alveolar crest, whereas the tensile and compressive stresses coincided with the apical sites clinically associated with root resorption. Stress levels were considerably greater in the multi-tooth system than in the single-tooth system. The results for the single-tooth model agree with those previously reported. The numeric studies show how orthodontic tooth movement develops different stress fields and how root resorption might occur as a result of hydrostatic compressive stress-induced tissue necrosis.

Physical properties of root cementum: Part 10. Comparison of the effects of invisible removable thermoplastic appliances with light and heavy orthodontic forces on premolar cementum. A microcomputed-tomography study

INTRODUCTION Orthodontic treatment with clear sequential removable thermoplastic appliances (TAs) is gaining popularity as an alternative to treatment with fixed appliances. The amount of orthodontically induced inflammatory root resorption generated by such appliances has not been investigated. In this prospective randomized clinical trial, we used x-ray microtomography to quantify resorption generated by treatment with ClearSmile appliances (ClearSmile, Woollongong, Australia) and compared the effects with those of heavy and light conventional orthodontic forces and no force. METHODS The sample consisted of 54 maxillary first premolars in 27 patients who required bilateral extractions as part of their planned orthodontic treatment. The subjects were randomly assigned to 3 groups, each with 9 subjects. A split-mouth design was used, and forces were applied to the first premolars. In group 1, TAs were used to move teeth on 1 side in a buccal direction at a rate of 0.5 mm every 2 weeks (TA movement); the contralateral teeth were not moved and served at controls. In group 2, TA movement was used on 1 side. A buccal force of 225 g from a beta-titanium alloy cantilever spring (heavy force) was used on the contralateral side. In group 3, TA movement was used on 1 side. A buccal force of 25 g from a cantilever spring (light force) was used on the contralateral side. The treatment duration was 8 weeks (56 days +/- 1 day). The TAs were changed every 14 days, and each patient used 4 appliances. The springs were not reactivated. At the end of the study period, the teeth were extracted according to a strict protocol to prevent root damage. Resorption was measured with an x-ray microtomograph (1072, SkyScan, Aartselaar, Belgium). Software analysis determined quantity, location, and distribution of root resorption craters. RESULTS The control teeth had the least amount of resorption. The light-force teeth had approximately 5 times more resorption than the control teeth (P <.001). The TA teeth had similar but slightly greater resorption than the light-force teeth, or approximately 6 times greater than the control teeth (P <.001). The heavy-force teeth had the most resporption, about 9 times greater than the controls (P <.001). CONCLUSIONS Clear removable TAs have similar effects on root cementum as light (25 g) orthodontic forces with fixed appliances.

Cephalometry and prediction of oral appliance treatment outcome

RationalePredicting which patients with obstructive sleep apnea (OSA) will be successfully treated with mandibular advancement splints (MAS) remains elusive. Developing simple daytime measurements and tests to predict treatment outcome would enhance MAS treatment.ObjectiveThe purpose of this study was to assess the clinical utility of anthropomorphic measurements and cephalometric X-rays in the prediction of MAS treatment outcome in OSA.MethodsAnthropomorphic measurements and cephalometric X-rays from 72 OSA patients who had presented to a tertiary referral sleep clinic were analyzed retrospectively.ResultsTreatment response was defined as ≥50% reduction in Apnea/Hypopnea Index (AHI; criterion 1); ≥50% reduction and residual AHI less than 20/h (criterion 2); ≥50% reduction in AHI and residual AHI less than 10/h (criterion 3); and ≥50% reduction in AHI and residual AHI less than 5/h (criterion 4). This was done to reflect the differences in the clinical definition of treatment success in the literature. A good response occurred in 56% (40 patients) according to criterion 1; 54% (39 patients) according to criterion 2; 46% (33 patients) according to criterion 3; or 39% (28 patients) according to criterion 4. Age and gender were found to be significant predictors for criteria 1 and 2. Age and soft palate length were found to be significant predictors for criteria 3 and 4. Equations to predict MAS treatment response were derived as equations were to predict final AHI.ConclusionsCertain cephalometric and anthropomorphic measurements impact on MAS treatment outcome. This study adds to the current literature and implies that MAS success is (to some degree) related to anatomical characteristics.

Effects of Steroidal and Nonsteroidal Drugs on Tooth Movement and Root Resorption in the Rat Molar

OBJECTIVE To test the hypothesis that the administration of aspirin, acetaminophen, meloxicam, celecoxib, and prednisolone have no effect on root resorption and tooth movement. MATERIALS AND METHODS A mesial force of 50 g was applied to the left maxillary first molars of sixty 10-week-old male Wistar rats using nickel titanium closed coil springs attached to the cervical area of the incisors. The rats were randomly divided into 12 groups of 5 each. High and low doses of aspirin, acetaminophen, meloxicam, celecoxib, and prednisolone were administered via drinking water for 2 weeks. The experimental control group had tooth movement but received no drug. The negative control group received neither tooth movement nor drugs. The amount of tooth movement was measured on digitized lateral cephalometric radiographs. Rats were sacrificed after 2 weeks. Mesial and distal roots (distobuccal and distopalatal) were examined using scanning electron and three-dimensional (3D) scanning laser microscopes. The surface area, depth, volume, and roughness of the root resorption craters were measured. RESULTS When compared with experimental control rats, only prednisolone- and high-dose celecoxib-treated groups showed significantly less root resorption and less tooth movement. Although low dose celecoxib-treated group significantly decreased the tooth movement, root resorption was similar to the control group. Furthermore, resorption craters showed a smoother surface in the prednisolone-treated rats. CONCLUSIONS The hypothesis was rejected. Administration of prednisolone and high-dose celecoxib reduces root resorption and interferes with tooth movement in rats. Both drugs may interfere in the arachidonic acid cascade depending on dose thresholds.

Esthetic evaluation of Asian-Chinese profiles from a white perspective

INTRODUCTION Immigration from Asian countries to North America and Australia has resulted in more Asian patients treated by white orthodontists. Planning treatment for patients of different ethnicities can be a challenge. The aim of this study was to establish baseline data for the assessment of Asian-Chinese profiles from a white perspective. METHODS Two Asian-Chinese profile images, 1 male and 1 female, were modified to create 7 profiles for each gender. Each profile showed a distinct characteristic: bimaxillary protrusion, protrusive mandible, retrusive mandible, normal profile (Class I incisor with Class I skeletal pattern), retrusive maxilla, protrusive maxilla, and bimaxillary retrusion. The images were viewed and ranked by 142 white examiners in 3 cohorts: 31 orthodontists, 31 dental students, and 80 laypersons from a mixed multi-ethnic metropolitan community. The facial anatomy that played the most important role in their decision making was also noted. Collected data in the form of ranks were statistically analyzed by using repeated measures analysis of variance. RESULTS All examiners preferred the normal Class I or bimaxillary retrusive profiles in both sexes; the male profile ranked the least attractive was the protrusive mandible, and the female profiles ranked the least attractive were the protrusive mandible and the retrusive mandible. Orthodontists, dental students, and laypersons demonstrated similar trends in ranking the profiles. The preferred profiles diverged from bimaxillary protrusive and Class III profiles (maxillary retrusion and mandibular protrusion), which are the usual norms for ethnic Asian-Chinese. The upper lip, the lower lip, and the chin had the most emphasis when the examiners were ranking the profiles. This finding was also common in all 3 groups. CONCLUSIONS This study demonstrated strong cohesive trends in establishing ideal facial esthetics of Asian-Chinese profiles evaluated by white persons in a multi-ethnic metropolitan community.

Magnetic activator device II (MAD II) for correction of Class II, division 1 malocclusions

A magnetically active, two-piece (upper and lower), functional orthopedic appliance has been developed, magnetic activator device (MAD) for the correction of Class II malocclusions. The magnetic forces are used to give freedom of mandibular movement and to allow for continuous functioning of the orofacial muscles when the appliance is worn. Samarium cobalt (Sm2Co17) magnets are incorporated on the buccal aspects of the upper and lower appliances. Magnetic forces ranging from 150 to 600 gm per side have been used on patients, and it seems that the skeletal versus dental response depends on the intensity of the magnetic force used. A force of 300 gm, when the magnets are in contact, on each side has been found to be an appropriate value in patients age 7 to 12 years. The use of this less bulky design rather than a traditional orthopedic appliance, along with the freedom of function it permits, has enabled patients to wear the appliance nearly 24 hours in most cases.