Editor's choice

Dealing with posterior crossbite in young patients

Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances

Residents’ journal review

In response to the letter by Aps1 concerning our papers published in DMFR2 and the September 2012 issue of the European Journal of Paediatric Dentistry (EJPD),3 we would like to provide clarification and evidence of the careful approach taken to the orthodontic and radiological procedures employed in these studies. Importantly, we would like to clarify that the authors do not use ionizing radiation as a daily orthodontic diagnostic tool. Careful dosage and ionizing radiation should be used only in specific clinical conditions such as impacted canines, supernumerary teeth and temporomandibular joint arthritis, and in planning orthognathic surgery.4 As was reported clearly in the article and could be seen easily in the figures, all patients in the study sample presented with severely displaced maxillary canines. Canine impaction is one of the clinical conditions in orthodontics for which evidence-based research for the clinical application of three-dimensional (3D) imaging exists. Thus, the primary indication for the low-dose CT was to evaluate the position of displaced intraosseus canines in the maxilla. These data cannot be detected using dental casts. While it is true that the position of the crown determines the surgical approach and direction of traction, the direction of eruption and location of the root apex play important roles in the orthodontic mechanics, avoiding damage to adjacent teeth and improving the effectiveness of canine traction.5 Hofmann et al6 developed a system on 3D imaging that allows for accurate evaluation of the position of the displaced canines relative to three spatial planes. The Department of Orthodontics at the University of Rome “Tor Vergata” is specialized in the treatment of impacted canines often associated with other dental anomalies such as supernumerary teeth and missing or peg-shaped lateral incisors.7,8 Consequently, we applied the protocol reported in several papers9–12 demonstrating that rapid maxillary expansion (RME) is an orthopaedic procedure that improves the initial intraosseus position of the canines and increases the rate of eruption of palatally displaced maxillary canines compared with an untreated control group. The present study sample is a very unique sample in the literature, and it allowed for scientific investigation of the skeletal, dental and periodontal effects of RME, one of the procedures most commonly applied and most debated in orthodontics. All of these effects (which cannot be derived using dental casts only) were analysed using the same sample in different publications by our research group.2,13–16 The imaging protocol in the present study was carefully planned with our radiologist to minimize patient dosage in low-resolution and small field of view (FOV) image acquisitions. The trained radiology technician reduced the voltage to the lowest possible level (80 kV) and restricted the area investigated strictly to the maxilla, adapting the FOV from a minimum of 6 cm to a maximum of 13 cm. Despite this, the accuracy of the measurements performed was not compromized. With this careful imaging protocol, the radiation dosage of three low-dose CT scans, considering their stochastic effect, is much smaller and not comparable to one multislice skull CT. The two images published in the EJPD demonstrate, contrary to what is claimed by Professor Aps, the high level of standardization involved where imaging acquisition was carried out by a single radiographer at the same scanner console, and the careful positioning of the patients' heads. Head position was standardized using perpendicular light beams, and the axial CT images were reconstructed always as parallel to the palatal plane and passing through the trifurcation of the right upper first molar, with the same method reported in numerous previous articles.17–28 For this reason, it was not necessary to add a figure; in addition, with the device in situ, it was possible to draw clearly the circle area because the expander was located in a more occlusal position at crown level, while the axial images were at the root level of anchored tooth. We thank Professor Aps for sharing the link to Image Gently, which is an initiative we certainly applaud. We absolutely agree that imaging as gently as possible, keeping the patient benefits and risks in mind, is our most sincere goal. In summary, as paediatric dentists, we are guarding over the health of our young patients, and as orthodontists, it is our duty to plan a treatment as conservative as possible, especially in clinical cases that need a combined surgical–orthodontic approach. Thus, all subjects of the study sample benefited from this research protocol and achieved successful treatment outcomes thanks to adequate treatment planning based on careful use of the right diagnostic tools.

Treatment outcomes in a graduate orthodontic clinic for cases defined by the American Board of Orthodontics malocclusion categories

Evaluation of the accuracy of digital model analysis for the American Board of Orthodontics objective grading system for dental casts

Three-dimensional assessment of buccal alveolar bone after rapid and slow maxillary expansion: A clinical trial study

Residents’ journal review

To review the long-term stability of slow maxillary expansion (SME) and rapid maxillary expansion (RME). A systematic review of literature was carried out on the principal medical databases. Cephalometric studies, measurements on the dental casts, retrospective, cohort studies were kept as inclusion criteria. Last 20 years articles were included in the study. The studies where expansion had been performed by any one of the methods of expansion; that is, SME and RME were accepted. Studies where posttreatment follow-up had been performed were included. Selected articles were independently evaluated by three researchers. Discrepancies were resolved by discussion to reach a common consensus. Total of 151 articles were first shown as relevant articles but after sorting the article according to relevancy in a stepwise manner 12 articles fulfilled the inclusion criteria and were incorporated in the study finally. In the study, nine prospective and three retrospective studies which had followed patients after maxillary expansion from 2 to 15 years were included. Correction with slow and rapid palatal expansion appears to be stable in the long-term when followed for extended periods after expansion treatment. The article clearly describes the effectiveness of the expansion treatment and its longitudinal stability in terms of relapse by providing various evidences from the literature which were sought after systematically searching the different electronic databases.

Aim: To demonstrate the main effects on maxillary and facial profile after treatment with expansion and face mask therapy in patients pattern III Class III. Material and Method: A cross-sectional study of maxillary expansion and reverse traction performed in 4 patients with maxillary deficiency, in the pre-peak pubertal growth stage and in the mixed dentition, with cephalograms before and after treatment, using angular measurements (SNA, SNENA, ANL and 1NA) and linear (S’-ENA, S’-A, 1-NA, OVERJET, S-LS and S-LI) and plot overlays. Results: Improvement in overjet was observed, going from negative to positive in all cases treated with incisor uncrossing, although it was not statistically significant. The upper and lower labial posture with respect to the base of the nose and the ment improved significantly, represented by the measurements S-LS and S-LI, with a change from the concave profile to slightly convex. Conclusion: Class III malocclusion with maxillary deficiency treated with rapid maxillary disjunction and reverse traction with facial mask was effective in both groups, with maxillary protraction and shifting in the concave to slightly convex profile.KeywordsFacial Mask; Rapid maxillary expansion; Class III.

Background: Assessment of treatment outcomes has traditionally been accomplished using the subjective opinion of experienced clinicians. Reduced subjectivity in the assessment of orthodontic treatment can be achieved with the use of an occlusal index. To implement an index for quality assurance purposes is time-consuming and subject to the inherent error of the index. Quality assessment of orthodontic treatment on a routine basis has been difficult to implement in private practice. Objectives: To investigate whether a clinician can accurately apply the American Board of Orthodontics Objective Grading System by direct visual inspection instead of measuring individual traits. Methods: A random sample of 30 cases was selected, including pretreatment and post-treatment upper and lower study casts and panoramic radiographs. The cases were examined and scored with the standardized measuring gauge according to the protocol provided by the American Board of Orthodontics (ABO). The records were re-examined 6 weeks later and the individual traits scored by visual inspection (VI). Results: There were no significant differences between the pre- and post-treatment ABO gauge and VI scores. Conclusions: This study suggests that occlusal traits defined by the ABO Objective Grading System can be accurately assessed by visual inspection. The VI score provides a simple and convenient method for critical evaluation of treatment outcome by a clinician.

We reported an 8-year-old male patient with Schwartz-Jampel syndrome, severe obstructive sleep apnea, constricted maxilla and moderate tonsillar hypertrophy. The syndrome is characterized by myotonia, skeletal dysplasia, and facial dysmorphism. CPAP was initially prescribed, but he was not able to tolerate due to a high pressure setting. Rapid maxillary expansion alone reduced AHI to 10.4 events/h. When combined with CPAP, AHI is further reduced to 2.4 events/h. The patient has a better compliance with CPAP following rapid maxillary expansion therapy as the pressure setting decreased. This is the first report utilizing a combination of rapid maxillary expansion and CPAP therapy to successfully treat severe pediatric OSA.

BackgroundMaxillary protraction with or without expansion is a widely known orthopedic treatment modality in growing skeletal Class III patients. However, limited data are available regarding the outcomes of long-term changes in the maxilla. Aim of this meta-analysis was to assess the effectiveness of the long-term maxillary anteroposterior changes following a facemask therapy with or without rapid maxillary expansion in growing skeletal Class III patients.MethodsA comprehensive literature search was conducted using the databases of PubMed, Science Direct, Web of Science, and Embase. Randomized controlled trials and cohort studies, published up to Sep. 2020, with maxillary protraction and/or expansion as keywords were included in this meta-analysis. Risk of bias within and across studies were assessed using the Cochrane tools (RoB2.0 and ROBINS-I) and GRADE approach. Overall and subgroup comparisons with the random-effect model were performed in this meta-analysis. Meta-regression models were designed to determine potential heterogeneity.ResultsThere was a statistically significant increase (Mean difference, 2.29°; 95% confidence interval, 1.86–2.73; and p < 0.001 after facemask (FM) protraction. Mean difference, 1.73°; 95% confidence interval, 1.36–2.11; and p < 0.001 after rapid maxillary expansion(RME) and facemask protraction) in the Sella-Nasion-A point (SNA) angle in the treatment groups as compared with the control groups, when measured during the less than 3-year follow-up period. However, no statistically significant changes (Mean difference, 0.28°; 95% confidence interval, -0.57–1.13; and p = 0.52 after facemask protraction. Mean difference, 0.34°; 95% confidence interval, -0.64–1.33; and p = 0.50 after rapid maxillary expansion and facemask protraction) were observed in the SNA angle in the groups, when measured after 3 years of follow-up. Meta-regression analysis also showed that with increased follow-up duration, the effectiveness of maxillary protraction decreased.ConclusionThis meta-analysis revealed that maxillary protraction therapy could be effective for a short-term in correcting maxillary hypoplasia and the treatment result was not affected by mean age and sex. However, with increased follow-up duration, the sagittal maxillary changes gradually decreased. Limitations on this review were only the SNA angle was used and clinical heterogeneity was not discussed. The quality of evidence was moderate. Further long-term observational studies are necessary for a comprehensive evaluation of the effects on maxillary skeletal changes.

Maxillary protraction with or without expansion is a widely known orthopedic treatment modality in growing skeletal Class III patients. However, limited data are available regarding the outcomes of long-term changes in the maxilla. Aim of this meta-analysis was to assess the effectiveness of the long-term maxillary anteroposterior changes following a facemask therapy with or without rapid maxillary expansion in growing skeletal Class III patients. A comprehensive literature search was conducted using the databases of PubMed, Science Direct, Web of Science, and Embase. Randomized controlled trials and cohort studies, published up to Sep. 2020, with maxillary protraction and/or expansion as keywords were included in this meta-analysis. Risk of bias within and across studies were assessed using the Cochrane tools (RoB2.0 and ROBINS-I) and GRADE approach. Overall and subgroup comparisons with the random-effect model were performed in this meta-analysis. Meta-regression models were designed to determine potential heterogeneity. There was a statistically significant increase (Mean difference, 2.29°; 95% confidence interval, 1.86-2.73; and p < 0.001 after facemask (FM) protraction. Mean difference, 1.73°; 95% confidence interval, 1.36-2.11; and p < 0.001 after rapid maxillary expansion(RME) and facemask protraction) in the Sella-Nasion-A point (SNA) angle in the treatment groups as compared with the control groups, when measured during the less than 3-year follow-up period. However, no statistically significant changes (Mean difference, 0.28°; 95% confidence interval, -0.57-1.13; and p = 0.52 after facemask protraction. Mean difference, 0.34°; 95% confidence interval, -0.64-1.33; and p = 0.50 after rapid maxillary expansion and facemask protraction) were observed in the SNA angle in the groups, when measured after 3 years of follow-up. Meta-regression analysis also showed that with increased follow-up duration, the effectiveness of maxillary protraction decreased. This meta-analysis revealed that maxillary protraction therapy could be effective for a short-term in correcting maxillary hypoplasia and the treatment result was not affected by mean age and sex. However, with increased follow-up duration, the sagittal maxillary changes gradually decreased. Limitations on this review were only the SNA angle was used and clinical heterogeneity was not discussed. The quality of evidence was moderate. Further long-term observational studies are necessary for a comprehensive evaluation of the effects on maxillary skeletal changes.

The rapid maxillary expander is one of the most widely used devices in orthodontics, and this study analyzes the skeletal and dental effects of a two-band rapid maxillary expander (RME) and a splint resin palatal expander (SRPE) in growing children with skeletal maxillary contraction. Seventy-four subjects with palatal skeletal contraction and unilateral or bilateral posterior crossbite were treated using maxillary expander devices. The sample was made up of two different randomly assigned groups: RME (21 females, 17 males; mean age ± SD 7.7 ± 1.1 years) and SRPE (24 females, 15 males; mean age ± SD 7.6 ± 1.0 years). The effects of these two different devices were evaluated based on lateral cephalograms and measurements of digital models before and after treatment (7.0 ± 1.0 months). Longitudinal changes in the different groups were evaluated statistically using Student’s t-test (p &lt; 0.05). No significant differences in treatment effects were found for any vertical or sagittal skeletal variables in the groups. However, there was a significantly increased maxillary intercanine distance in the SRPE group (36 patients; mean ± SD = 6.0 ± 4.8 mm) compared to the RME group (38 patients; mean ± SD = 3.1 ± 2.9 mm). The results of this study showed an increase in vertical skeletal dimensions in more patients treated using SRPE than RME. Moreover, the SRPE device was shown to be better at increasing the intercanine distance, and it could therefore be preferred in children with anterior dental crowding. An evaluation of long-term treatment stability would be useful to confirm the study results.