Combined Orthodontic-surgical Approach Research Articles

Inhibition of miR338 rescues cleidocranial dysplasia in Runx2 mutant mice partially via the Hif1a-Vegfa axis

Haploinsufficiency of Runt-related transcription factor-2 (RUNX2) is responsible for cleidocranial dysplasia (CCD), a rare hereditary disease with a range of defects, including delayed closure of the cranial sutures and short stature. Symptom-based treatments, such as a combined surgical-orthodontic approach, are commonly used to treat CCD patients. However, there have been few reports of treatments based on Runx2-specific regulation targeting dwarfism symptoms. Previously, we found that the miR338 cluster, a potential diagnostic and therapeutic target for postmenopausal osteoporosis, could directly target Runx2 during osteoblast differentiation in vitro. Here, we generated miR338−/−;Runx2+/− mice to investigate whether inhibition of miR338 could rescue CCD defects caused by Runx2 mutation in vivo. We found that the dwarfism phenotype caused by Runx2 haploinsufficiency was recovered in miR338−/−;Runx2+/− mice, with complete bone density restoration and quicker closure of fontanels. Single-cell RNA-seq analysis revealed that knockout of miR338 specifically rescued the osteoblast lineage priming ability of bone marrow stromal cells in Runx2+/− femurs, which was further confirmed by Osterix-specific conditional knockout of miR338 in Runx2+/− mice (OsxCre; miR338fl/fl;Runx2+/−). Mechanistically, ablation of the miR338 cluster in Runx2+/− femurs directly rescued the Hif1a-Vegfa pathway in Runx2+/− osteoblasts, as proven by gene expression profiles and ChIP and Re-ChIP assays. Collectively, our data revealed the genetic interaction between Runx2 and the miR338 cluster during osteoblast differentiation and implied that the miR338 cluster could be a potential therapeutic target for CCD.

Evaluation of Postoperative Pain and Discomfort in Patients Undergoing Surgical Exposure of Impacted Maxillary Canines.

ABSTRACTObjectivesThe purpose of the retrospective study was to evaluate pain and discomfort related to surgical exposure according to initial localization of impacted maxillary canines.Material and MethodsPre-treatment cone-beam computed tomography (CBCT) data and discomfort evaluation questionnaire of 25 patients (17 female, 8 male), treated with combined surgical-orthodontic approach was analysed. The questions included: level of discomfort during surgery (0 to 10), level of pain (0 to 10) in the evening, one, two days and a week after surgery. CBCT analysis consisted of evaluation of impacted maxillary canines mesiodistal inclination, horizontal, vertical dislocation from alveolar process edge, labiopalatal localization and length of eruption path. To carry out research objectives a Spearman and interclass correlation coefficients, Mann-Whitney U test, Cohen’s kappa coefficient were used. Level of significance was 0.05.ResultsAverage level of discomfort during the procedure was 2.8 (SD 2.3). Pain level the evening after the surgery was the highest - 3.3 (SD 2.1) and decreased over the week. Pain level differed significantly between different days (P < 0.001). Neither labial or palatal location nor the unilateral or bilateral impaction had effect on the level of pain (P > 0.05). The results showed that pain during different stages of measuring as well as level of discomfort during surgical exposure did not differ statistically significantly depending on severity of impaction (P > 0.05).ConclusionsThere was no significant relation between the discomfort and the location of the impacted canine. Patient’s gender or age did not have an impact on discomfort and pain.

Orthosurgical management of deckbiss malocclusion (Class-II Div 2) in adult patients: A case series

Class II malocclusion cases are of interest to orthodontists since they constitute a significant chunk of cases they treat. Still, they're one of the most grueling malocclusions to diagnose and treat.There lies a significant difference in the frequency of Class II malocclusion among various populations. The frequency of Class II malocclusion in India varies from 1.9% in Rajasthan to 8.37% in South India. Class II division 2 (Deckbiss) malocclusion is characterized by mandibular incisors positioned posterior to the cingulum of retroclined maxillary incisors. It usually presents with reduced overjet and increased overbite.The treatment approach of Class II division 2 malocclusion is different for different age groups. In growing cases, growth modulation with myofunctional appliances is recommended but in adult cases, orthodontic camouflage or orthognathic surgery is the recommended treatment modality. When orthodontic treatment alone is ineffective or when facial aesthetics is grossly undermined, orthognathic surgery is the choice of treatmentIn the present case series, two adult cases of severe Class II division 2 (Deckbiss) malocclusion were treated orthosurgically with BSSO. This case series demonstrates that treatment of Class II division 2 (Deckbiss) malocclusion in adult patients is a challenging task and a combined orthodontic-surgical approach can be used to obtain optimum aesthetics &amp; functional efficiency.

Comprehensive management of severe skeletal Class III malocclusion through a combined surgical and orthodontic approach

Management of skeletal Class III malocclusion requires a comprehensive approach since several factors such as severity of reverse overjet and facial divergence govern the treatment plan. Management of the nongrowing skeletal Class III individual with moderate-to-severe skeletal discrepancy is either by surgical management or orthodontic camouflage. Although various reports emphasize that both the treatment options are equally successful, the degree of correction which can be achieved differs. This report describes the comprehensive management of a case of severe skeletal Class III malocclusion through a combined surgical-orthodontic approach.

Are age and radiographic features effective on orthodontic alignment of palatally impacted maxillary canines? a retrospective study.

The purpose of the study was to evaluate the effects of age and radiographic parameters on success of orthodontic alignment of impacted maxillary canines. The retrospective records of 50 patients (mean age 20.44 years) who had impacted maxillary canines in palatal position were included. The patients was requiring surgical exposure and mechanical orthodontic treatment were divided into two groups as adolescent (age≤18; n=24) and adult (age>18; n=26). In both groups, the treatment time and success were evaluated clinically and radiographically. Fifty patients between the ages of 13 to 42 (12 males and 38 females) with palatally impacted canines were treated with combined surgical-orthodontic approach. Forty-seven teeth (94%) had reacted to surgical exposure and orthodontic alignment within 16 to 36 months with a mean of 24.81 months. Three of the impacted canines (6%) were surgically removed because no movement was observed following 10 months of traction forces. The distance of the canine tip to the occlusal plane on the lateral cephalometric radiographs have found to be related with the total orthodontic treatment time. Neither the age of the patient nor other clinic and radiographic parameters had influence on the treatment results of alignment of maxillary canines following surgical exposure.

Clinical Outcome of an Impacted Maxillary Canine: From Exposition to Occlusion

The aim is to report a case of impacted maxillary right canine successfully positioned into the occlusion line. Although the treatment of choice for an impacted canine is a combined surgical-orthodontic approach, there are differences in technique. The preorthodontic uncovering and autonomous eruption technique is a safe and predictable option for the treatment of palatally impacted maxillary canines in adolescents and adults as is the orthodontic creation of a space before minimal surgical exposure, the bonding of a small attachment (an eyelet), full-flap closure, and immediate traction. Although the mechanical management of impacted teeth is a routine task for most orthodontists, certain types of impaction can be frustrating. An 18-year-old adult patient presented for clinical examination with a mobile maxillary right deciduous canine, the absence of a maxillary right permanent canine, Angle Class I malocclusion, an overjet of 2.0 mm, an overbite of 3.0 mm, and rotated canine and left maxillary central and lateral incisors. Cephalometric measurements revealed a skeletal Class I relationship as well as upright maxillary incisors (1. NA = 18°) and mandibular incisors (1. NB = 16°, IMPA = 80°). The facial profile was concave. Clinically, a constricted maxillary arch was observed, and the patient had a nail-biting habit. The canine was aligned, leveled and positioned in the occlusion line. The esthetic, functional and periodontal results remained stable in the retention phase. Various treatment strategies are available to treat impacted maxillary canines. The surgical, periodontal, and orthodontic considerations in the management of impacted canines must be clearly explained to the patient.

Improvement in three-dimensional facial configuration and jaw motion following surgical orthodontic treatment of a case with jaw deviation

The establishment of normal stomatognathic function and an acceptable facial appearance is considered an important treatment goal in orthodontics. The patient, who demonstrated posterior crossbites and jaw deviation, underwent treatment with a combined orthodontic-surgical approach utilizing maxillary transverse distraction osteogenesis, Le Fort I osteotomy, and bilateral SSRO. The smoothness of the masticatory jaw-closing movement and three-dimensional facial configuration were compared pre- and post-treatment. Correction of the posterior crossbites enabled the patient to perform smoother jaw-closing movements during chewing. Additionally, asymmetry in the morphology of the chin, cheek, and lips was reduced. These favorable changes in masticatory jaw movement kinematics and three-dimensional evaluation of the face justify the application of surgical-orthodontic treatment to improve jaw function and facial appearance.

Change in the Vertical Relation in Class II Deformity with Skeletal Open Bite in the Orthognathic Surgery

The continuously growing esthetic awareness for the facial appearance and the spreading of information about the possibilities of adult treatment by public media result in an increase of adult patients seek orthodontic treatment to improve their facial esthetics. In general, these patients show such a severe skeletal deformity that it is detectable even by non-experts because of its extraoral manifestation, which is the main motivation for treatment. Because of the nature of these deformities and because of the lacking growth usable for therapy the only promising treatment for these patients is the combined orthodontic-surgical approach. Besides a stable and functional occlusion with physiologic position of the condyle, the goals of treatment are the improvement of the dental and, above all, facial esthetics since the patient judges the success of treatment mostly by the extraoral appearance. The dentofacial appearance must be defined prior to treatment to plan the individual right approach in knowledge of the different treatment possibilities for Angle Class II deformities and thus be able to reach both sides -patient and orthodontist- satisfying result. With this article a systematic therapy concept to treat patients with Class II deformities and skeletal open bite with a long lower face (long face syndrome).

A Therapeutic Concept by “Watted” for the Surgical Lengthening of the Lower Face by Short Face Syndrome

The continuously growing esthetic awareness for the facial appearance and the spreading of information about the possibilities of adult treatment by public media result in an increase of adult patients which seek orthodontic treatment to improve their facial esthetics. In general, these patients show such a severe skeletal deformity that it is detectable even by non-experts because of its extraoral manifestation, which is the main motivation for treatment. Because of the nature of these deformities and because of the lacking growth usable for therapy the only promising treatment for these patients is the combined orthodontic-surgical approach. Besides a stable and functional occlusion with physiologic position of the condyle, the goals of treatment are the improvement of the dental and, above all, facial esthetics since the patient judges the success of treatment mostly by the extraoral appearance. The dentofacial appearance must be defined prior to treatment to plan the individual right approach in knowledge of the different treatment possibilities for Angle Class II deformities and thus be able to reach for both sides—patient and orthodontist—satisfying result. With this article, a systematic therapy concept to treat patients with Class II deformities and skeletal deep bite with a short lower face (short face syndrome) under consideration of the soft tissue analysis is presented.

Unilaterally impacted maxillary central incisor and canine with ipsilateral transposed canine-lateral incisor

Concurrent impaction and transposition of maxillary anterior teeth is uncommon and poses a challenge for dentists. Early diagnosis and management of eruption disturbances benefits esthetic and functional outcomes. This article describes the treatment of a teenager who had impactions of the left maxillary central incisor and canine as well as ipsilateral canine-lateral incisor transposition. Treatment alternatives and effective orthodontic techniques are delineated. To optimize the treatment results, the impacted maxillary canine was surgically exposed and orthodontically distalized with an innovative cantilever. Subsequently, the deeply impacted maxillary central incisor was uncovered and orthodontically mesialized into the arch. Finally, the displaced maxillary lateral incisor was brought into its normal position. The combined surgical-orthodontic approach resolved a difficult clinical issue and avoided additional restorations. An esthetic, functional outcome was achieved and satisfied the patient.

To beam or not to beam: that is the question: Author response

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.

Trattamento ortodontico-chirurgico di canini mascellari inclusi. Caso clinico

ObjectivesCombined surgical-orthodontic treatment of impacted maxillary canines has advanced significantly in recent years, regarding management of both hard and soft tissues and forces of traction. The aim of this report is to describe a combined surgical-orthodontic approach used to treat an impacted maxillary canine and to evaluate the functional and esthetic results after 5 years of follow-up. Materials and methodsA 13-year-old boy was seen in the Operative Unit of Orthodontics of Policlinico Tor Vergata in Rome. Radiographic images showed intraosseous impaction of tooth no. 2.3 in a setting of late mixed dentition, and the patient was scheduled for the combined surgical-orthodontic treatment. ResultsFive years after the combined treatment, the patient presented good occlusal stability.The maxillary canine that had been orthodontically repositioned showed keratinized mucosa of adequate width on the facial side with a margin that followed the course of the enamel-cement junction. Bleeding was absent on probing, the periodontal pocket depth was <4mm, and there was no radiographically evident bone loss. ConclusionsThe combined surgical-orthodontic technique used in this case (closed eruption towards the center of the alveolar ridge associated with conservative periodontal surgery, the acid-etch technique, and controlled orthodontic traction) simulates physiological tooth eruption and results in proper alignment with good periodontal results. It should thus be regarded as the treatment of choice for impacted teeth whose eruption is not precluded by the position of the tooth and/or the presence of ankylosis.

Management of unilaterally deep impacted first, second, and third mandibular molars

Simultaneous impactions of first, second, and third permanent molars comprises a very rare clinical situation with diverse therapeutic approaches and is a difficult challenge for dentists. Early diagnosis and treatment of eruption disturbances contributes to optimal outcomes. This article reports the treatment of a teenager with severe impaction of right mandibular first, second, and third molars, which hinders the masticatory function and dental arch integrity. A decision-making process and a simple orthodontic technique are described. To shorten the treatment time and simplify the procedures, the impacted right mandibular third and second molars were orthodontically uprighted with an innovative tip-back cantilever. Subsequently, the deeply impacted right mandibular first molar was extracted with minimal obstacles. The combined surgical-orthodontic approach resolved a challenging clinical problem and eliminated the need for prosthetic or dental implant replacement of the impacted molars. Good occlusion, normal function, and a healthy periodontium of the patient were also achieved.

Success rate of anterior open-bite orthodontic-orthognathic surgical treatment

The aim was to evaluate the short-term success rate of combined orthodontic-orthognathic surgical correction of anterior open bite. Fifteen patients (ages, 15-28 years) with open bite treated with a combined orthodontic-surgical approach were examined. Lateral cephalograms from before treatment, after treatment, and after an average of 18 months (range, 10-26 months) of retention were evaluated. Overbite was classified as normal (2-3.5 mm), borderline (0-1.5 mm), or relapse (<0 mm), and overjet as normal (2-3.5 mm) or relapse (≥4 and ≤1.5 mm). The average overbite was -3.2 mm before treatment, 1.8 mm after treatment, and 1.3 mm after retention. During active treatment, overbite and overjet were normalized in 53.3% and 66.7% of the subjects, respectively. After the retention period, 1 patient (6.7%) showed a negative overbite, whereas a borderline overbite was found in 53.3% of the subjects. Overjet relapsed in 40% of the subjects. Only 40% of the patients had a completely successful treatment with incisal contact and normal overjet and overbite. Orthodontic-surgical treatment of anterior open bite improves the overbite, but an excellent treatment outcome with normal overjet and overbite and proper incisal contact was achieved in only 40% of the subjects.

Factors affecting the clinical approach to impacted maxillary canines: A Bayesian network analysis

The aim of this study was to apply Bayesian networks to evaluate the relative role and possible causal relationships among various factors affecting the diagnosis and final treatment outcome of impacted maxillary canines. A total of 168 patients with infraosseous impacted maxillary canines had a combined surgical-orthodontic approach aimed to guide the impacted tooth to the center of the alveolar ridge. Demographic, orthodontic, and periodontal variables were recorded and analyzed by means of Bayesian network analysis. All 168 impacted canines were successfully moved and aligned in the dental arches with healthy periodontiums. According to the Bayesian network analysis, bilateral impaction was associated with palatal impaction and longer treatment; the pretreatment alpha-angle was a determinant for the duration of orthodontic traction, also because of the associations between greater angulation of impacted canines with more severe tooth displacement and with greater distance of the impacted canine from the occlusal plane; the posttreatment periodontal outcome was not related to the pretreatment radiographic variables. Bayesian network analysis was useful to identify possible relationships among the variables considered for diagnosis and treatment of impacted canines.

Surgically assisted Maxillo-mandibular transverse expansion

The skeletal correction of transverse maxillary deficiency is difficult via orthodontics and orthopedics after 18 years of age and is successful until the age of approximately 13-15 yearsdepending on the gender of the patient [1, 2]. After the skeletal maturity, orthodontic treatment alone cannot provide stable widening of constricted maxilla. The area of increased skeletal resistance to expansion is indeed not the midpalatal suture, but the pterygomaxillary, zygomatico temporal, zygomatico frontal and zygomatico maxillary [3, 4]. The skeletal mandibular transverse deficiency is a difficult clinical situation to handle by orthodontic means alone. This case report highlights the successful management of transverse maxillo-mandibular discrepancy by combined orthodontic-surgical approach.

Alveolar bone grafting in the treatment of midline alveolar cleft and diastema in incomplete median cleft lip

Median cleft lip is a rare congenital anomaly. The wide diastema with mesial tipping observed in these patients has been largely overlooked. A midline submucosal alveolar cleft prevents adequate treatment. The purpose of this article is to describe an alveolar bone grafting (ABG) technique used in the combined surgical-orthodontic approach to diastema treatment in patients presenting with incomplete median cleft lip. Patients treated for incomplete median cleft lip and diastema were identified in the clinic registry from 1981 to 2007. Six patients were identified; 4 underwent ABG before permanent maxillary incisor eruption, the other 2 were seen later when they were 11 years old. All 6 ABGs were successful. The incisors erupted through the graft or were successfully moved into it with lasting results. Follow-up ranged from 8 to 21 years. The existence of a midline submucosal alveolar cleft and subsequent diastema should be recognized and addressed in all patients who present with incomplete median cleft lip repair. This includes taking maxillary occlusal view X-rays before the age of 5 years to detect the cleft, and proceed to ABG if necessary, generally before permanent maxillary incisor eruption.

Non-surgical Treatment of Mutilated Severe Skeletal Class II Malocclusion with Hyperdivergent Growth Pattern - A Case Report

Malocclusion, with a superimposed vertical growth tendency, is often difficult to treat without a combined surgical orthodontic approach. Certain situations, however, may preclude surgery as a treatment option. The following case report demonstrates the use of orthodontic mechanotherapy alone in successfully treating a patient that exhibited a mutilated Angle's Class II Division 1 malocclusion, complicated by missing teeth, mandibular shift, anterior open bite, and a dolicofacial skeletal pattern.

Initial Vertical and Horizontal Position of Palatally Impacted Maxillary Canine and Effect on Periodontal Status Following Surgical-Orthodontic Treatment

To evaluate the impact of surgical-orthodontic treatment and the initial vertical and mesiodistal position of palatally impacted maxillary canines on the periodontal health of impacted canines and adjacent teeth. The study group consisted of 32 patients with unilateral palatally impacted maxillary canines. The initial position of the impacted canines was assessed on panoramic images. The treatment protocol of the impacted canines included surgical exposure with the closed-eruption technique and fixed orthodontic appliances. A significant increase in pocket depth was found at the canine mesiopalatal point after surgical-orthodontic treatment. Also, a correlation was found between the initial mesiodistal and vertical position of the impacted canine and the posttreatment periodontal status of the impacted canine, the adjacent lateral incisor, and the first premolar. A combined surgical-orthodontic approach in the treatment of impacted maxillary canines produces clinically acceptable periodontal conditions. The average increase in pocket depth was less than 4 mm and clinically unimportant for most patients.

A therapeutic concept for the combined orthodontic surgical correction of angle Class II deformities with short‐face syndrome: Surgical lengthening of the lower face

In today's society not only facial esthetics have become important, but also the information on ways to correct adult orthodontic problems is readily available. Subsequently, increasing number of adults seek orthodontic treatment merely to change their facial appearance. In general, these adult patients exhibit such a severe skeletal deformity that it is noticeable even by non-experts. The nature of these adult deformities is such that the only promising treatment is the combined orthodontic-surgical approach. A stable and functional occlusion with a physiologic position for the condyle is the common goal of orthodontic treatment. In patients with skeletal deformities, however, improvement of facial esthetics takes paramount importance. They judge the success of treatment by extraoral appearance. Accordingly, the clinician must assess both the dental and facial appearance, and then inform the patient of different treatment possibilities. In this scenario, patient's input into the decision making process is critical for a mutually satisfactory result. This clinical report describes a concept of systematic approach to treatment of Class II deformities with skeletal deep bite and short lower face (short-face syndrome). This approach emphasizes the soft tissue analysis.