Michael P. Major

Soft Tissue Changes with Fixed Functional Appliances in Class II division 1

OBJECTIVE To evaluate facial soft tissue changes after the use of fixed functional appliances in Class II division 1 malocclusion cases using a systematic review of the literature. MATERIALS AND METHODS Several electronic databases (PubMed, Medline, Medline In-Process & Other Non-Indexed Citations, Cochrane Database, Embase, Web of Sciences, and Lilacs) were searched with the help of a senior Health Sciences librarian. Abstracts that appeared to fulfill the initial selection criteria were selected by consensus. The original articles were then retrieved. Their references were also hand-searched for possible missing articles. Clinical trials assessing facial soft tissue changes with the use of fixed functional appliances without any surgical intervention or syndromic characteristics were considered. A comparable untreated control group was required to factor out normal growth changes. Four articles using Herbst and one using Jasper Jumper fulfilled the selection criteria. An individual analysis of these articles was made and some methodological flaws were identified. RESULTS Although fixed functional appliances produce some significant statistical changes in the soft tissue profile, the magnitude of the changes may not be perceived as clinically significant. CONCLUSIONS The conclusions from this systematic review should be considered with caution because only a secondary level of evidence was found. Long-term double-blinded prospective randomized clinical trials are needed. Three-dimensional quantification of the soft tissue changes is required to overcome current limitations in our understanding of the soft tissue changes obtained with the use of fixed functional appliances.

Le Fort III Distraction Osteogenesis Versus Conventional Le Fort III Osteotomy in Correction of Syndromic Midfacial Hypoplasia: A Systematic Review

PURPOSE It has been debated whether the Le Fort III procedure using distraction osteogenesis (LFIII-DO) reduces the risk of postintervention relapse compared with conventional Le Fort III (LFIII) osteotomy in the correction of syndromic midfacial hypoplasia. Our objective was to evaluate the short- and long-term stability of the bony structures after midfacial advancement using conventional LFIII osteotomy versus LFIII-DO in patients with syndromic midfacial hypoplasia. MATERIALS AND METHODS We performed a systematic review of the published data. An electronic search of 10 databases was performed from their inception through June 2012. The reference lists of the relevant publications were also reviewed. Studies were considered for inclusion if they were longitudinal clinical studies with follow-up periods of at least 1 year after surgery (LFIII group) or at the end of the consolidation period (LFIII-DO group). Study selection, risk of bias assessment, and data extraction were performed in duplicate. The methodologic and clinical heterogeneity across the studies precluded combining the findings using meta-analyses. RESULTS A total of 57 reports met the initial search criteria, and 12 reports were finally selected. The studies demonstrated a mean midfacial advancement of 8 to 12 mm in the LFIII group and 9 to 16 mm in the LFIII-DO group. For the LFIII group, horizontal short-term follow-up showed a maximal rate of relapse of 8.7 to 11.9% in 2 studies, with 1 study demonstrating a far more severe rate of maximal relapse of 50%. For the LFIII-DO procedure, the horizontal short-term relapse rate was 14.4% in 1 study, with the remainder demonstrating a rate of relapse of less than 10%. Moreover, 3 studies even showed additional advancement without any rate of relapse. CONCLUSIONS Current evidence suggests that conventional LFIII and LFIII-DO techniques can effectively advance the midface forward in patients with syndromic midfacial hypoplasia and have good to excellent stability, with a mild rate of relapse. However, the LFIII-DO technique appears to achieve a greater amount of advancement with a lower rate of relapse compared with the conventional LFIII technique.

Long-term skeletal stability after maxillary advancement with distraction osteogenesis in cleft lip and palate patients.

OBJECTIVE To systematically review the long-term skeletal stability after maxillary advancement with distraction osteogenesis (DO) in cleft lip and palate (CLP) patients. MATERIALS AND METHODS Electronic databases, grey literature, and reference list searches were conducted. The inclusion criteria were stability of maxillary advancement with distraction osteogenesis assessed at the posttreatment follow-up ≥ 1 year in CLP patients. Full articles were retrieved from abstracts or titles that appear to meet the inclusion criteria or lacked sufficient detail for immediate exclusion. Once full articles were collected, they were again reviewed considering more detailed inclusion criteria for a final selection decision. A methodologic quality assessment tool was utilized. RESULTS Thirty abstracts/titles met the initial search criteria, and 13 articles were finally selected. Overall, methodologic quality scores were high in only one randomized clinical trial. After maxillary advancement with DO in CLP patients, the long-term horizontal relapse in A-point was less than 15% in eight studies and between 20% and 25% in four studies. The study that was judged as a high-quality study reported 8.2% horizontal relapse in A-point. The relapse rate was higher in DO with external distracter device than DO with internal distracter device. CONCLUSIONS Current evidence suggests maxillary advancement with DO has good stability in CLP patients with moderate and severe maxillary hypoplasia.

A descriptive analysis of oral health systematic reviews published 1991-2012: cross sectional study.

Objectives To identify all systematic reviews (SRs) published in the domain of oral health research and describe them in terms of their epidemiological and descriptive characteristics. Design Cross sectional, descriptive study. Methods An electronic search of seven databases was performed from inception through May 2012; bibliographies of relevant publications were also reviewed. Studies were considered for inclusion if they were oral health SRs defined as therapeutic or non-therapeutic investigations that studied a topic or an intervention related to dental, oral or craniofacial diseases/disorders. Data were extracted from all the SRs based on a number of epidemiological and descriptive characteristics. Data were analysed descriptively for all the SRs, within each of the nine dental specialities, and for Cochrane and non-Cochrane SRs separately. Results 1,188 oral health (126 Cochrane and 1062 non-Cochrane) SRs published from 1991 through May 2012 were identified, encompassing the nine dental specialties. Over half (n = 676; 56.9%) of the SRs were published in specialty oral health journals, with almost all (n = 1,178; 99.2%) of the SRs published in English and almost none of the non-Cochrane SRs (n = 11; 0.9%) consisting of updates of previously published SRs. 75.3% of the SRs were categorized as therapeutic, with 64.5% examining non-drug interventions, while approximately half (n = 150/294; 51%) of the non-therapeutic SRs were classified as epidemiological SRs. The SRs included a median of 15 studies, with a meta-analysis conducted in 43.6%, in which a median of 9 studies/1 randomized trial were included in the largest meta-analysis conducted. Funding was received for 25.1% of the SRs, including nearly three-quarters (n = 96; 76.2%) of the Cochrane SRs. Conclusion Epidemiological and descriptive characteristics of the 1,188 oral health SRs varied across the nine dental specialties and by SR category (Cochrane vs. non-Cochrane). There is a clear need for more updates of SRs in all the dental specialties.

Correlations Between Acoustic Rhinometry, Subjective Symptoms, and Endoscopic Findings in Symptomatic Children With Nasal Obstruction

IMPORTANCE Nasal obstruction is common in children and difficult to quantify objectively. Symptom quantification is paramount for surgical and medical decision making. Acoustic rhinometry is a relatively new technique aimed at the objective assessment of nasal obstruction. There is no standardized method for the objective assessment of the pediatric nasal airway. OBJECTIVE To explore the correlations between acoustic rhinometry (AR), subjective symptoms, and endoscopic findings in children presenting with nasal obstruction. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional, exploratory, diagnostic study of prospectively collected data from a multidisciplinary airway clinic (pulmonology, orthodontics, and otolaryngology) database at a tertiary academic referral center. Data were collected over a 2-year period (2010-2012) from 65 nonsyndromic children (38 boys) 7 years and older (mean [SD] age, 10.3 [2.5] years [range, 7-14 years]), presenting with persistent nasal obstructive symptoms for at least 1 year, without signs and symptoms of sinus disease. INTERVENTIONS We collected patient demographics and medical history information including allergy, asthma, and sleep-disordered breathing. Subjective nasal obstruction was scored using a visual analog scale (VAS). Sleep-disordered breathing was assessed using overnight pulse oximetry. The adenoid size, septal position, and visual severity of chronic rhinitis (endoscopic rhinitis score [ERS]) were rated on nasal endoscopy by 2 independent reviewers and validated by agreement. Acoustic rhinometry (AR) was undertaken before and after use of a decongestant. MAIN OUTCOMES AND MEASURES Correlation and multiple regression analyses were performed to explore interrelationships between subjective nasal obstruction VAS, AR, and nasal endoscopy. RESULTS Among the 65 patients, 28 (43%) had symptoms of sleep-disordered breathing, 14 (22%) had allergic rhinitis, 10 (15%) had asthma, 27 (41%) had grade 3 or 4 adenoidal obstruction, 28 (43%) had an ERS of 2, 6 (9%) had an ERS of 3, and 19 (29%) had septal deviation. Significant correlations were found between subjective nasal obstruction VAS score and ERS (r = -0.364, P = .003), ERS and minimal cross-sectional area before decongestion (r = -0.278, P = .03), and adenoid size and calculated nasal resistance after decongestion (r = 0.430, P < .001). Multiple regression analysis showed that the ERS was the only significant predictor of VAS score (β of -22.089; 95% CI, -35.56 to -8.61 [P = .002]). No predictors were identified for AR variables. CONCLUSIONS AND RELEVANCE Among the evaluated tools, endoscopy appears to be the most reliable tool to estimate the degree of subjective nasal symptoms.

The accuracy of diagnostic tests for adenoid hypertrophy: A systematic review

BACKGROUND Adenoid hypertrophy may cause sleep-disordered breathing and altered craniofacial growth. The authors conducted a study to gauge the accuracy of alternative tests compared with nasoendoscopy (reference standard) for screening adenoid hypertrophy. METHODS The authors conducted a systematic review that included searches of electronic databases, hand searches of bibliographies of relevant articles and gray literature searches. They included all articles in which an alternative test was compared with nasoendoscopy in children with suspected nasal or nasopharyngeal airway obstruction. RESULTS The authors identified seven articles that were of poor to good quality. They identified the following alternative tests: multirow detector computed tomography (sensitivity, 92 percent; specificity, 97 percent), videofluoroscopy (sensitivity, 100 percent; specificity, 90 percent), rhinomanometry with decongestant (sensitivity, 83 percent; specificity, 83 percent) and clinical examination (sensitivity, 22 percent; specificity, 88 percent). Lateral cephalograms tended to have good to fair sensitivity (typically 61-75 percent) and poor specificity (41-55 percent) when adenoid size was evaluated but excellent to good specificity when airway patency was evaluated (68-96 percent). CONCLUSIONS No ideal tool exists for dentists to screen adenoid hypertrophy, owing to access constraints, radiation concerns and suboptimal diagnostic accuracy. Research is needed to identify a low-risk, easily acceptable, highly valid diagnostic screening tool. PRACTICAL IMPLICATIONS Although lateral cephalograms (which have good to fair sensitivity) and a thorough medical history (which has good specificity) are imperfect individually, when they are used together, they can compensate for each others weaknesses. This combined approach is the best tool available to dentists for screening adenoid hypertrophy.

Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review

OBJECTIVE To evaluate the effectiveness of mandibular advancement appliances (MAAs) for treatment of pediatric obstructive sleep apnea (OSA). METHODS Several electronic databases (The Cochrane Database, EMBASE, Healthstar, MEDLINE, PubMed) were systematically searched, as well as a limited grey literature (Google Scholar) and manual searches. A health sciences librarian helped with the selection of Medical Subject Headings (MeSH), key words, and combinations of key words with truncations to account for any differences in controlled terminology in the different databases. Only studies that evaluated the effects of MAAs in children with OSA were pursued. RESULTS Only 4 articles satisfied all inclusion criteria. Selected studies were retrospective except one study that was a quasi-randomized clinical trial. High risk of bias (Cochrane Risk of Bias assessment) was judged in all included studies. Based on the limited available evidence use of MAAs in a POSA population may result in improvements in Apnea Hypopnea Index (AHI) scores. However complete normalization of AHI scores was not demonstrated. Heterogeneity in study designs and collected information precluded meta-analysis. LIMITATIONS There are significant weaknesses in the existing evidence due primarily to absence of control groups, small sample sizes, lack of randomization and short-term results. Determination of AHI scores with MAAs still in the mouth should be avoided. CONCLUSIONS The current limited evidence may be suggestive that MAAs result in short-term improvements in AHI scores, but it is not possible to conclude that MMAs are effective to treat pediatric OSA. Medium- and long-term assessments are still required.

Developing an index for the orthodontic treatment need in paediatric patients with obstructive sleep apnoea: a protocol for a novel communication tool between physicians and orthodontists

Introduction Sleep disordered breathing in the paediatric population can manifest as an array of different systemic symptoms; among them is a distinct malocclusion and craniofacial phenotype. Emerging research suggests that the treatment of this malocclusion and/or craniofacial phenotype through orthodontic intervention may help with the symptoms of these patients. Selecting the patients who would benefit from orthodontic treatment can be a difficult task for the physician with minimal dental training. Therefore the aim of this study is to develop a simple index to be used by medical professionals to identify those paediatric patients with orthodontic treatment needs who may benefit their obstructive sleep apnoea (OSA) symptoms. Methods and analysis The methodology in this project has been devised through the WHOs recommendations on developing an index, with modifications based on the specific needs of this study. Based on the available literature, a draft index will be produced and subjected to multiple iterative revisions based on the feedback from: the Index Development Group, a group of multidisciplinary and internationally acclaimed experts in the field; the External Review Group, a group of potential end users and interested parties and the Steering Committee. Once the index has been formalised, it will be subjected to a pair of reliability tests using physicians and orthodontists scored 2 weeks apart. Subsequently, the index will be validated using dichotomous responses from orthodontists on whether they would treat a patient for OSA symptoms, and comparing the responses to the score of the index on the same patient. Ethics and dissemination The index will be translated into French and will be presented in orthodontic and medical conferences, workshops, seminars, round table discussions, and free copies for download will be made available on the website of the University of Alberta Interdisciplinary Airway Research Clinic (iarc.ualberta.ca). Furthermore, the index will be published in a peer-reviewed medical journal to further increase the exposure of the index.

The effect of buccal–lingual slot dimension size on third-order torque response

Introduction The focus of the presented study was to investigate the effect of buccal-lingual (B-L) orthodontic bracket slot dimension on third-order torque mechanics. Materials and methods Three types of orthodontic brackets and two archwire sizes were considered. Ortho Classic H4 (0.026″ B-L slot, passive), Ormco Damon Q (0.028″ B-L slot, passive), and In-Ovation R (0.028″ slot, active) brackets were tested using 0.017″ × 0.025″ and 0.019″ × 0.025″ beta-titanium archwires. An in vitro orthodontic torque simulator (OTS) was used to rotate archwires relative to a single bracket while recording forces and moments in three directions. For each bracket-archwire combination, a total of n = 47 samples were tested. Repeated measures analysis of variance between brackets was conducted for third-order torque values at 3° increments between 9° and 30° during loading and unloading for each archwire size. Results Statistically significant differences between H4 and Q brackets were only found for 0.017″ × 0.025″ archwires during loading, and 0.019″ × 0.025″ archwires during unloading. Conversely, differences between H4 and R brackets were found for both archwires during loading and unloading phases. Finally, when using a 0.017″ × 0.025″ archwire the H4 brackets reached the 5 Nmm threshold before R and Q brackets; however, there was little difference found when using a 0.019″ × 0.025″ archwire. Conclusions The concept of using a smaller B-L bracket slot dimension in orthodontic treatment showed it may theoretically allow for more options, primarily using smaller archwires to correct third-order rotational misalignments. However, it is suspected that bracket material limitations and added loading on the door currently prevent this from being clinically applicable.

Nasal septum changes in adolescent patients treated with rapid maxillary expansion

Objective: To analyze cone-beam computed tomography (CBCT) scans to measure changes in nasal septal deviation (NSD) after rapid maxillary expansion (RME) treatment in adolescent patients. Methods: This retrospective study involved 33 patients presenting with moderate to severe nasal septum deviation as an incidental finding. Out of these 33 patients, 26 were treated for transverse maxillary constriction with RME and seven, who did not undergo RME treatment, were included in the study as control group. CBCT scans were taken before appliance insertion and after appliance removal. These images were analyzed to measure changes in nasal septum deviation (NSD). Analysis of variance for repeated measures (ANOVA) was used. Results: No significant changes were identified in NSD regardless of the application or not of RME treatment and irrespective of the baseline deviation degree. Conclusion: This study did not provide strong evidence to suggest that RME treatment has any effect on NSD in adolescent patients; however, the results should be interpreted with caution, due to the small sample size and large variation amongst individual patient characteristics.