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ISSN : 0974 - 9098
Volume 43, Number 1 January - March, 2009
The Journal of
Indian Orthodontic Society
The JIOS is the Official Publication of the Indian Orthodonic Society
The Journal of Indian Orthodontic Society
Official publication of Indian Orthodontic Society (Reg. No. 16920/68
Published quarterly : March, June, September, December
Editor
Dr. Lodd Mahendra
Associate Editor
Dr. P Janardhanam
Consultant Editors
Dr. M.R. Balasubramaniam
Dr. Ashima Valiathan
Dr. K. Jyothindra Kumar
Dr. M.K. Prakash
Dr. K. Sadashiva Shetty
Dr. N.R. Krishnaswamy
Assistant Editors
Dr. Ashwin M. George
Dr. S. Venkateswarn
Dr. G. Shivaprakash
Committee for reviews and
abstracts
Dr. Chetan V. Jayade
Dr. Santha Sundari
Dr. Sridevi Padmanabhan
Dr. A. Nandakumar
Dr. P. Navaneetha Krishnan
Dr. M.S. Rani
INDIAN ORTHODONTIC
SOCIETY
Office Bearers (2009)
President
Dr. O. P. Kharbanda
Journal Committee
Dr. R.B. Sable
Dr. Sanjay Ganeshkar
Dr. Jayesh Rahalkar
Dr. Jayaram Mailankody
Dr. K. Ketan Vakil
Dr. Rabindra S. Nayak
Dr. P. Ganesh
Dr. Sarojini Joseph
Dr. M.S. Ravi
Dr. Sandhya Jain
Dr. Divakar Karanth
Dr. Nikhil S. Vashi
Dr. Vinod Krishnan
Dr. K. Ravi
Dr. Krishnaraj
Dr. Girish Karandikar
Dr. Joseph Varghese
Dr. Rittu Dugai
Dr. K. Uma Shankar
Hon. Secretary
Dr. E.T. Roy
President - Elect
Dr. Girish R. Karandikar
Immediate Past President
Dr. N. R. Krishnaswamy
Vice President
Dr. Arun A. V
Hon. Joint Secretary
Dr. G. Sivaprakash
Hon. Treasurer
Dr. Kishore M.S.V.
Editor JIOS
Dr. Lodd Mahendra
Journal Consultative Board
Dr. V.P. Jayade
Dr. S. Rangachari
Dr. V. Surendra Shetty
Dr. A.S. Kalha
Dr. Akhter Hussain
Dr. O.P. Kharbanda
The Journal of Indian Orthodontic Society (JIOS) Welcomes,
contributions both from India and abroad. It’s aim is to publish
clinical, research and review articles of interest to Orthodontists
in India and throughout the world. The Journal is published by
the Indian Orthodontic Society.
No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic,
mechanical photocopying, recording or otherwise, without the
prior permission of the Editor.
Statements and opinions expressed in the articles and
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necessarily those of the Editor, Publisher or Association. The
Editor, Publisher or Association do not endorse any product or
service advertised in this publication, also they do not guarantee
any claim made by the manufacturer of such product or service.
Applications for advertising space / position should be addressed
to the Editor JIOS.
Executive Committee Members
Dr. Anil Kumar Mehrotra Dr. Murukesan S.
Dr. Nikhilesh R. Vaid
Dr. Anup Kanase
Dr. Nillan Shetty K.
Dr. Ashish Gupta
Dr. Prakash A. T.
Dr. Ashuthosh Shetty
Dr. Rajashekhar K.
Dr. Chaturvedi T. P.
Dr. Rajeev Lall
Dr. Deepak C.
Dr. Ramachandra C. S.
Dr. Hazarey P. V.
Dr. Rani M. S.
Dr. Joe Ezakias Rozario
Dr. Vishal Gupta
Dr. Kohli V. S.
INDIAN BOARD OF
ORTHODONTICS
Founded in 1999 by
The Indian Orthodontic Society
Board of Directors
Dr. V. Surendra Shetty
Chairman
Dr. Mani K. Prakash
Vice Chairman
Dr. K. Shadashiva Shetty
Secretary - Treasurer
Dr. R.B. Sable
Director
Dr. Vinod Varma
Director
Editorial Office : 48, 4th Street, Padmanabha Nagar, Adyar
Chennai - 600 020. E-mail : editorjios@gmail. com
1
Volume 43
Number 1
January - March 2009
CONTENTS
President’s Message
3
Editorial
4
Evaluation of Lateral Ptergoid Muscle in Temporomandibular
Disorder Patients - A MRI Study (Part I)
5
Evaluation of Lateral Ptergoid Muscle in Temporomandibular
Disorder Patients - A MRI Study (Part II)
10
“Cephalometric Evaluation Based on Steiners Analysis on Young
Adults of Assam”
17
Ortho-surgical Management of Class III Malocclusion in Identical
Twins - Care Report
23
Maxillary Protraction Therapy
40
Evaluation of Proximal Alveolar Bone Level changes during
Orthodentic Treatment
48
43rd IOS Conference
58
2
President’s Message
Greetings and good wishes
from
President Indian Orthodontic Society
Professor OP Kharbanda takes over 32nd President of the Indian Orthodontic Society
(2008-2009) at the ceremony held during 43rd Indian Orthodontic Conference, Mumbai
of the India.
Dear Colleague,
• Active and visible
representation of IOS at
international forum such
as
Asian
Pacific
Orthodontic Society, World Federation of
Orthodontics, and possibly formation of SAARC
Orthodontic Society, in the immediate future.
I have a sense of gratitude to the members of the Indian
Orthodontic Society for having expressed faith in this
tiny soul to lead the society which had been initiated
by great professionals more than 40 years ago. I humbly
accept this responsibility and would try with utmost
sincerity to take the society a step forward to the best
of my ability. I am aware of the fact that the strength of
our society lies in its members and I am merely their
representative. My thoughts and plans, some of them
immediate and others have been long term goals which
I may only be able to initiate are listed below. I feel
privileged and happy to carry out responsibilities
entrusted upon me by my predecessors and I would
expect my followers to carry on the flag forward too.
• Regular publication of the Indian Orthodontic
Journal so that we can initiate Process of it being
indexed and publishing a society newsletter at a
regular interval.
• Initiate “Indian Association of Orthodontic
Educators”
Please feel free to write to secretary Indian Orthodontic
Society with CC to me or directly if you have
suggestions advice or any other queries with regards
to Indian Orthodontic Society.
Orthodontic Practice and Treatment Delivery
• Quality assurance in Orthodontic clinical practice.
• Promotion and formation of regional / city
orthodonctic discussion groups.
• Promotion of Orthodontics among public at large
and health care workers, medical specialist doctors,
nurses and all paramedical workers.
• Greater interaction with other specility associations
for expanded role of orthodontist as an important
team members of Oral health Care providers,
particularly on aspects of adult care, inter
disciplinary cleft care and sleep medicine.
• Orthodontic care for most needy at free / affordable
cost through a voluntary pledge scheme by
members. “Offer a smile” or “your smile is mine
too.”
All efforts will be made to address the issues.
I would greatly appreciate if members can come
forward and help us to achieve goal together.
May I take this opportunity to wish you and your family
a very prosperous and happy new Year 2009 and good
times ahead in life.
With kind personal regards
Professor OP Kharbanda
BDS, MDS (Lucknow), M Orth RCS (Edinburgh),
M MEd (Dundee) FAMS
Fellow Indian Board of Orthodontics: Honoris
Causa
Head, Department of Orthodontics
Centre for Dental Education and Research
Adjunct Professor and Coordinator
KL Wig centre for Medical Education and
Technology
Orthodontic Education and Research
• Seek a significant role of Indian Orthodontic Society
in making decisions on orthodontic education in
the country and request for Speciality Association
representation at Dental Council of India and
inititate Orthodontic Speciality registration.
• To train the trainers on Principals of education,
advances in education technology research and
methodologies and publications.
All India Institute of Medical Sciences
New Delhi 110029 INDIA
Phone + 91-9899062144
E Mail [email protected]
3
EDITORIAL
Dear Members,
Greetings from the editorial Team. Efforts are being taken to get the journal indexed
and as a first step in that direction, the ISSN number for the journal has been
allotted. The aspirations of the members of the society in improving the quality
and regularity of the journal queries of the authors who submit articles can be
met to a large extent, if the society enlists the services of a publishing house. We
as the editorial team are aware of the need and will take appropriate steps.
The issues of this year will exhibit the work of our members from across the
length and breathe of our country and will also encourage our members to publish
their work in the near future.
— Dr. LODD MAHENDRA
4
EVALUATION OF LATERAL PTERYGOID MUSCLE IN
TEMPOROMANDIBULAR DISORDER PATIENTS - A MRI STUDY
Part I
Authors :
Dr. Amol S. Patil, BDS, MDS (ORTHODONTIA)
Lecturer, Department of Orthodontics,
Bharati Vidyapeeth Dental College and Hospital
e-mail:- [email protected]
Ph:-91-09850814846
Dr. Ravindra B. Sable
Abstract:
Lateral pterygoid muscle (LPM) was evaluated in Non TMD subjects(control group) as well as TMD patients(study
group).15 controls were used and 20 patients were used. Patients with lateral pterygoid muscle myalgia was the
main criteria for selection of patients. Questionnaire was filled up for each patient and lateral pterygoid was
evaluated for every patient with help of MRI. In control group, the LPM in 86.67% patients appeared normal with
no pathological changes in the muscle. LPM appeared as a fan shaped muscle with dense homogeneous signal
with well defined borders. Both, the superior and inferior of the LPM were visible on the oblique sagittal view.
Statistically significant presence of fatty degeneration was noted in the study group (p<0.01). MRI abnormalities of
the lateral pterygoid showed close associations with the main symptoms of TMD. i.e. All patients(100%) with
pain and condylar hypermobility had significant presence of fatty degeneration in LPM.
INTRODUCTION
various imaging tools.6,7,8 Thus MRI promises to be one
of the important tools in evaluating the status of lateral
pterygoid muscle in diagnosis of TMD.
Temporomandibular disorders (TMD) refer to a
collection of medical and dental conditions affecting
the Temporomandibular joint and/or the muscles of
mastication, as well as contiguous tissue components.
The correct diagnosis of TMD is the most important
factor in successful treatment. In the past during the
diagnostic process of TMD problems, the imaging
techniques were mainly focused on the head of the
condyle, glenoid fossa, articular disc, ligaments and
joint spaces but the muscles of mastication have always
been neglected.
Aims :-The aims of this study are:a. To evaluate MRI findings of the lateral pterygoid
muscle in non-TMD subjects.
b. To evaluate pathological changes in the lateral
pterygoid muscle by using MRI in patients suffering
from TMD.
c. To compare MRI findings of the lateral pterygoid
muscle with the clinical symptoms of TMD.
It is a known fact that the LPM has a close association
with TMD. However because of difficulties in palpation
of the muscle due to its anatomical location, difficulty
in placement of electrodes accurately in the muscle
for EMG studies1,2,3,4,5 and radiation hazards associated
with CT scan this muscle still has not been studied to a
great extent.
This study was designed to investigate MRI finding of
LPM in non TMD subjects (control group) and to
evaluate the pathological changes in LPM by using MRI
in patients suffering from TMD.
Materials and Methods:- Total sample size was 46
individuals, amongst which 31 were patients who
reported to Department of Orthodontics and
Dentofacial Orthopedics, Bharati Vidyapeeth Dental
College and Hospital, suffering from painful symptoms
of TMJ of long duration. 15 volunteers, who did not
suffer from any symptoms of TMD, were used as control
group.
MRI is a non-invasive, non-ionizing, patient friendly
imaging tool, which gives precise and accurate
information about the soft tissues. Therefore this technique
can be very useful in studying the lateral pterygoid muscle,
thus overcoming the drawbacks and limitations of the
5
Observations and Results :-
Following were the criteria for selection of patients
1) Patients with history of pain and tenderness and/or
Temporomandibular joint sounds only on one side
for more than 6 months duration.
TABLE I : DISTRIBUTION OF VOLUNTEERS WITH
FATTY CHANGES
2) Age above 15 years and below 40 years.
Fatty changes in
muscles
3) No specific criteria for occlusion was considered.
No.of patients
4) No specific criteria for limitations in mouth opening
was considered.
PRESENT
ABSENT
TOTAL
3
(20%)
12
(80%)
15
(100%)
The above table shows that 20% of the volunteers had
fatty change while 80% volunteers had normal muscle
structure.(p>0.05N.S.)
Following were the criteria for exclusion of patients:1) Patients with tenderness of muscles other than LPM
were excluded from the above sample.
TABLE II : DISTRIBUTION OF PATIENTS WITH
FATTY CHANGES
2) Patients suffering from bilateral TMJ signs and
symptoms.
Fatty changes in
muscles
Thus 11 patients were excluded from the study sample
of 46. Total number of subjects became 35, including
15 volunteers from control group i.e. Total 70 joints
were studied.
No.of patients
PRESENT
ABSENT
TOTAL
17
(85%)
3
(15%)
20
(100%)
The above table shows that 85% of patients had fatty
change in the muscle and 15% patients had no fatty
change in the muscle.(p<0.01.S)
The study was performed with a 0.2-T magnet
(Magnetom,Siemens), T1- weighted (528/12-20/1or2)
(TR range/TE range/ excitations), T2- weighted (4100/
123/1) and Proton Density (PD)(2000-3000/14-30/1),
with 2-mm
thick imaging slices, a 10X10 field of
view (FOV) and a 256X123 or 172X250 dots per
inch matrix were used for the images.
TABLE III : TYPE OF PAIN AND ITS DISTRIBUTION
PERSISTENT
An open design “C” shaped magnet was used to
increase patients comfort and operator ease.(Fig 1)
Male
Female
Total
% age
3
(30%)
7
(70%)
10
50
RECURRENT
All the patients underwent bilateral MRI examinations
of the TMJ with brain surface-coil. Oblique sagittal and
coronal projections of lateral pterygoid muscle were
used in mouth-closed position.
Scanning Planes
Locator imaging:- The location of condyle and
scanning planes was determined on cross-section
locator imaging of TMJ.
Male
Female
Total
% age
7
(70%)
3
(30%)
10
50
The above table depicts 50% of patients had recurrent
pain and 50% had persistent pain.
TABLE IV:- DISTRIBUTION OF SEVERITY OF PAIN
AND FATTY CHANGE
Coronal imaging:- The scanning planes were
located in anatomical sagittal and coronal direction
(Fig 2).
SEVERITY OF PAIN
Oblique sagittal:- The scanning planes were
perpendicular or parallel to the long axis of the lateral
pterygoid (Fig 3).
Slice thickness was 2mm and 12 slices were taken for
coronal imaging and 6 slices were taken for sagittal
imaging. 2 films per patients were printed.After
completion of all scanning procedure for all the
patients, the interpretation of the MRI finding of LPM
was done with the help of a Radiologist .Following
was the interpretation for normal and abnormal finding
of LPM.
V.A.S
Number of
patients
1-3
4-6
7-10
5
7
8
Presence of
fatty change
4
(80%)
5
(71.4%)
8
(100%)
The above table shows that 80% of patients having
pain on VAS between 1-3 had fatty degeneration,
71.41% of patients having pain on VAS between 4-6
had fatty degeneration and 100% of patients having
pain on VAS between 7-10 had presence of fatty
degeneration in LPM.
6
identified in MRI (Schellhas10, Benito et al).In the present
study the LPM did not appear homogenous but diffuse
hyperintense zones were visible in the muscle mass.
(Fig 6 & 7)The margins of the muscle were not well
defined. Presently there is no method of classification
to define the quantum of fatty degeneration in the
muscle due to the diffuse nature of the pathology and
the three dimensional structure of the LPM. According
to the radiologists interpretation we have classified
the fatty change into mild, moderate and severe.
Hypertrophy was not compared as variations in size of
the muscle between individuals might relate to many
factors, including skeletal size, age, sex and general
health (Schellhas10, van Spronsen et al). Size and
morphological comparing in the same individual with
the asymptomatic side also has not been used in the
diagnosis of hypertrophy in the LPM as even the
opposite side had fatty degeneration in a few subjects.
The result in this study found that the MRI abnormal
findings of the LPM showed a close association with
functional manipulation pain of the muscle. 85%(17)
patients from the study sample of 20 showed fatty
degeneration in the LPM whereas 15% (3) patients did
not show fatty degeneration even though they had pain
and click.(Table II)
It was also observed that the unaffected side LPM also
showed evidence of fatty degeneration in some patients.
45% patients ie 9 patients had pathological findings
on opposite side even though the patient was
asymptomatic on that side. On statistical analysis, p
value > 0.05 confirms that the finding of fatty
degeneration on unaffected side was not statistically
significant.(Table VI)
Fatty degeneration can also be attributed to the muscle
spasm which results in a decrease in blood supply to
the affected part resulting in accumulation of the
metabolic waste products and certain alogogenic
substances(eg bradykinin , prostaglandins) which cause
muscle degeneration and muscle pain.11
In this study , on correlating the presence of fatty
degeneration in LPM and the type of pain (TableIII), it
was noticed that 40% patients had recurrent pain and
60% patients had persistent pain. No statistical
significance was found between type of pain and
presence of fatty degeneration (p value >0.05).
In the present study presence of limited mouth opening
was seen in 30% of patients where as presence of fatty
degeneration was seen in all (100%) the patients with
limited mouth opening. On statistical evaluation
statistically significant correlation(p value < 0.01) was
found between limited mouth opening and presence
of fatty degeneration.(Table VII)
TABLE V : DISTRIBUTION OF PATIENTS WITH
FATTY CHANGES AND CLICK AND PAIN
Fatty changes in
muscles +CLICK
PRESENT
ABSENT
TOTAL
5
(83.33)
1
(16.67)
6
The above table shows that 5 patients reported positive
and 1 negative.
TABLE VI : SIDE WISE DISTRIBUTION OF
PATIENTS WITH FATTY CHANGES ON
UNAFFECTED SIDE
SIDE
LEFT
RIGHT
TOTAL
Fatty changes in
muscles
6
(30%)
3
(15%)
9
(45%)
The above tables shows that 45% had changes on
opposite side, 30% had fatty changes on left side and
15% had changes on right side
TABLE VII : DISTRIBUTION OF PATIENTS WITH
FATTY CHANGES AND LIMITED MOUTH
OPENING
Fatty changes in
limited mouth
opening
PRESENT
ABSENT
TOTAL
6
(100%)
0
(100%)
6
The above table shows that all the patients with limited
mouth opening (6 patients) had presence of fatty change
in the LPM.(p<0.01)
DISCUSSION :In order to diagnose pathological changes in the LPM,
it was necessary to observe both bellies clearly on the
images. Anatomical studies of the LPM have reported
that the anterior part of the two bellies are separated
by a space, or gap, which is filled by fibrous and adipose
tissue and usually contains the maxillary artery, but
the two bellies blend, or fuse, together near the insertion
(Sicher, Wilkinson9).Imaging of the LPM in present study
agreed with these anatomical findings.The two bellies
could be well identified on the image with the anterior
gap between the two bellies.(Fig:-4 & 5) This gap
between was near the origin side of the LPM. When
this gap was observed, it indicated that the most part
of the LPM had been shown on the image and the image
was suitable for diagnosis of morphological and signal
intensity changes of LPM. However the two bellies
could not be separately identified on all images due to
low resolution of the MRI (Magnetom) machine used
in this study which is 0.2 Tesla.
PATHOLOGICAL CHANGES OF LPM
Pathological changes of the LPM in TMJ
hypermobility
Diagnosis of atrophy of the LPM was based on signal
changes of fatty replacement, which can be well
Clinically, different terms have been used to denote
TMJ hypermobility, such as recurrent luxation of TMJ
7
5)
(Holmlund et al12), recurrent mandibular dislocation or
recurrent subluxation of TMJ (Sacks et al.13). The most
common clinical complaint of symptomatic condyle
hypermobility is clicking with painful symptoms related
to TMJ and masticatory muscles (Katzberg et al, Holmlund
et al.12). Similar clinical symptoms of TMJs with condylar
hypermobility were also found in present study.
The abnormalities of the LPM were also significantly
more often found in the TMJs with symptomatic
hypermobility. (Table V)83;33 % patients suffering from
TMJ hypermobility patients had fatty degeneration.
Presence of fatty degeneration in patients with TMJ
hypermobility is statistically significant (p value < 0.01)
These findings show that pathological changes of the
LPM and condyle hypermobility may play important
roles in giving rise to the symptoms in the TMD.
6)
7)
8).
CONCLUSION
Following conclusions were derived from the study
In control group, the LPM in 86.67% patients
appeared normal with no pathological changes
in the muscle. LPM appeared as a fan shaped
muscle with dense homogeneous signal with well
defined borders. Both, the superior and inferior of
the LPM were visible on the oblique sagittal view.
In 85% of patients suffering from lateral pterygoid
myalgia, significant pathological change i.e. fatty
degeneration was seen in the LPM. The LPM did
not appear homogeneous but diffuse hyperintense
zones were visible in the muscle mass.
MRI abnormalities of the lateral pterygoid showed
close associations with the main symptoms of
TMD. i.e. All patients(100%) with pain and
condylar hypermobility had significant presence
of fatty degeneration in LPM.
Obviously, histological confirmation of the imaging
pathological finding in the LPM is very important and
further research is needed in the future.
9)
10)
11)
12)
13)
REFERENCE:
1)
2)
3)
4)
Phanachet, T. Whittle, K. Wanigaratne, and G. M.
Murray Functional Properties of Single Motor Units
in Inferior Head of Human Lateral Pterygoid
Muscle:Task Relations and Thresholds .J
Neurophysiol 2001;86: 2204-2218.
Widmalm SE, Lillie JH, Ash MM Jr. Anatomical and
electromyographic studies of the lateral pterygoid
muscle. J Oral Rehabil. 1987 ;14(5):429-46.
Koole P, Beenhakker F, Jongh HJ, Boering G .A
standardized technique for the placement of
electrodes in the two heads of the lateral pterygoid
muscle. Cranio. 1990 ;8(2):154-62.
Dahan J, Boitte C .Comparison of the
reproducibility of EMG signals recorded from
human masseter and lateral pterygoid muscles. J
Dent Res. 1986;65(3):441-447.
Orfanos T, Sarinnaphakorn L, Murray GM,
Klineberg IJ. Placement and verification of
recording electrodes in superior head of the
human lateral pterygoid muscle.Arch Oral
Biol.1996 ;41(5):493-503.
Liu ZJ, Yamagata K, Kuroe K, Suenaga S, Noikura
T, Ito G. Morphological and positional assessments
of TMJ components and lateral pterygoid muscle
in relation to symptoms and occlusion of patients
with Temporomandibular disorders.J Oral Rehabil.
2000 ;27(10):860-74.
Yang X ,Pemu H, Pyhtinen J, Tiilikainen A,
Oikarinen KS, Raustia AM.MRI findings
concerning the lateral pterygoid muscle in patients
with symptomatic TMJ hypermobility. Cranio.
2001;19(4):260-8.
Yang X, Pernu H, Pyhtinen J, Tiilikainen PA,
Oikarinen KS, Raustia AM. MR abnormalities of
the lateral pterygoid muscle in patients with
nonreducing disk displacement of the TMJ.
Cranio.2002;20(3):209-21.
Wilkinson TM. The relationship between the disk
and the lateral pterygoid muscle in the human
temporomandibular joint. J Prosthet Dent.1988;
60(6):715-724.
Kurt P.Schellas.MR Imaging Of Mastication. Am J
Roentgenol.1989;153(4):847-55.
Jeffery Okeson. Management of Temporomandibular Disorders and Occlusion. Edition 4
.Mosby Pub;1995.
Holmlund AB, Axelsson S, Gynther GW. A
comparison of discectomy and arthroscopic lysis
and lavage for the treatment of chronic closed
lock of the Temporomandibular joint: a
randomized outcome study. J Oral Maxillofac
Surg. 2001; 59(9):972-7; discussion 977-8.
Sacks H, Zelig D, Schabes G. Recurrent
Temporomandibular joint subluxation and facial
ecchymosis leading to diagnosis of Ehlers-Danlos
syndrome: report of surgical management and
review of the literature. J Oral Maxillofac
Surg.1990; 48(6):641-647.
Fig 1: Magnetom(Siemiens) 0.2 T MRI Machine
8
LOCALISER IMAGES
Fig 2:-Sagittal oblique section
Fig 3:- Coronal section
Fig 5:-Normal MRI of LPM d-superior belly, e- inferior
belly.
Fig 4:-Normal MRI of LPM a-LPM muscle, b-condyle,
c- pterygoid plates
Fig 6:-Fatty degeneration of LPM on oblique sagittal
view f- fatty degeneration appearing as diffuse
hyperintensities
Fig7 .Fatty degeneration of LPM on coronal view f-fatty
degeneration seen as hyperintense zones
9
EVALUATION OF LATERAL PTERYGOID MUSCLE BEFORE AND
AFTER STABILIZATION APPLIANCE THERAPY - A MRI STUDY
Part II
Authors :
Dr. Amol S. Patil, BDS, MDS (ORTHODONTIA)
Lecturer, Department of Orthodontics,
Bharati Vidyapeeth Dental College and Hospital
e-mail:- [email protected]
Ph:-91-09850814846
Dr. Ravindra B. Sable
Abstract:
The aim of the study was to evaluate the effects of stabilization appliance on lateral pterygoid muscle in patients
suffering from TMD with help of MRI. In the present study 10 patients suffering form lateral pterygoid myalgia
were treated with stabilization appliance for three months. Questionnaire was filled up for each patient and
lateral pterygoid was evaluated for every patient with help of MRI. 90% patients showed significant regression in
fatty degeneration and 100% patients showed significant decrease in painful symptoms. A clinically significant
increase in size of the muscle was also seen in 90% of the patients indicating a decrease in atrophy of the muscle.
Thus stabilization appliance plays a important role in decrease in fatty degeneration in the lateral pterygoid
muscle as well as concomitant decrease in painful symptoms of the TMJ.
Keywords:
(Lateral Pterygoid muscle, Stabilization appliance, MRI)
In management of TMD intraoral stabilizing appliances
are routinely used. The purpose of a stabilizing
orthopedic appliances is to provide stabilization to the
intracapsular structures of the TMJ, to distribute the
occlusal forces evenly, to create stability in the muscles
of mastication and to protect the dentition from
excessive wear. These appliances are designed to fit
over maxillary or mandibular arches and used for short
duration. Even though there is no clear understanding
of the physiologic mechanism of the response to
intraoral orthopedic appliance usage, various studies
by Raphael K, Marbach JJ1 , Juan Carraro , Raul
Caffesse2, Terry T ,Major A3 , Alex W4 , Ekberg E5 ,
Kuttila M et al.6 , Ekberg EC, Vallon D, Nilner M7
Ekberg E, Nilner M8 documents the effectiveness of
stabilization appliance in the reduction of painful
symptoms of TMJ as well as in the muscles of
mastication. However very few studies have included
any diagnostic tool or physical parameter to confirm
the mechanism of action of the stabilizing appliance.
Aims and Objectives of study:1. To evaluate the effects of stabilization appliance
on lateral pterygoid muscle in patients suffering
from TMD with help of MRI.
2. To hypothesize a scientific explanation for changes
occurring in Lateral Pterygoid muscle after three
months stabilization splint therapy.
Evaluation of effects of stabilizing splint therapy
on the pathology detected by imaging technologies
shall help in an effective management of patients
suffering from TMD.
Materials and Methods
Total number of patients were 20 selected from the
Part I study group. 20 patients with lateral pterygoid
muscle MRI were selected along with the following
selection criteria.
10
to the Research Diagnostic Criteria was filled by the
patient and documented The Visual Analogue Scale of
0 to 10 (10 cm scale, with 1 cm division where 0 is
“no pain” and 10 is “pain as bad as could be”) was
given to the patient to rate her or his facial pain.
Criteria for selection was
1) Patients suffering from lateral pterygoid muscle
myalgia.
Following were the criteria for exclusion of patients :1) Presence of click.
A hard acrylic maxillary stabilizing appliance was
delivered to all the 10 selected patient’s .Splint was
fabricate with help of vacuum forming machine(Biostar)
as mentioned by Okeson and Glenn.
2) Patients undertaken orthodontic treatment or
occlusal rehabilitation in the past.
After exclusion total study sample consisted of 10
patients with Lateral Pterygoid myagia i.e. Total 20
joints were studied.
All participants were explained the need and design of
the study. Potential benefits of undergoing a thorough
TMJ examination, Magnetic Resonance Imaging
investigation were made known to these participants.
Consent was obtained on a separate prescribed form
and only those individuals who consented to undergo
these procedures were included in the study
The patients returned in 15 days for evaluation
initially and subsequently once a month. The lateral
pterygoid muscle and TMJ examinations were repeated
at each subsequent visit to determine whether the
signs and symptoms are being eliminated.
Questionnaire was filled ever month. After 3 months
once again the MRI was taken for all the patients using
the same MRI machine, same technique and same MRI
parameters. MRI films were processed the same manner
and interpreted by the same Radiologist.
All these individuals were assessed using a pre-designed
and structured methodology. Patients were made to sit
comfortably in a dental chair. Questionnaire according
After interpretation of all MRI films, observation tables
were prepared and were subjected for statistical
analysis.
Observations
TABLE I : DISTRIBUTION OF PATIENTS WITH RESPONSE TO SPLINT THERAPY
Fatty changes in
muscles
NO CHANGE
SIGNIFICANT CHANGE
TOTAL
1
(10%)
9
(90%)
10
(100%)
The above table shows that 9 (90%) patients showed significant decrease in fatty change in the lateral pterygoid
muscle and 1(10%) showed no change.
TABLE II : DISTRIBUTION OF PATIENTS WITH DECREASE IN FATTY CHANGES
Fatty changes in
muscles
MIN. SIGNIFICANT
SIGNIFICANT
MOD. SIGNIFICANT
1
(11.11%)
1
(11.11%)
7
(77.78)
The above table shows that 77.78% showed significant changes, 11.1% showed minimal change and 11.1% showed
very significant changes.
11
TABLE III : DISTRIBUTION OF PATIENTS WITH DECREASE IN PAIN SYMPTOMS AFTER
STABILIZATION APPLIANCE
Decrease in pain
MIN. SIGNIFICANT
SIGNIFICANT
MOD. SIGNIFICANT
1
(10%)
5
(40%)
4
(50%)
The above table illustrates that 50% of patients had significant reduction in painful symptoms and 40 % patients had
moderate reduction in painful symptoms and 10% patients had minimally significant reduction in painful symptoms
TABLE IV : DISTRIBUTION OF PATIENTS WITH DECREASE IN FATTY CHANGES AND WITH
DECREASE IN PAIN SYMPTOMS AFTER STABILIZATION APPLIANCE
No of patients
DECREASE IN
FATTY CHANGE
DECREASE IN
PAINFUL SYMPTOMS
PERCENTAGE OF
IMPROVEMENT
9
(90%)
10
(100%)
90%
All the patients had (100%) had a decrease in painful symptoms but only 90% patients had a decrease in fatty change
after appliance therapy.
Table V:-This table depicts the size of muscle of the LPM before treatment and the size of LPM after treatment
Sr. No.
Before Treatment
(cm)
After Treatment
(cm)
Left
Right
Left
Right
1.
3.23 x 2.95
2.58 x 2.51
3.54 x 3.06
2.78 x 2.69
2.
4.07 x 2.20
3.63 x 2.35
4.19 x 2.37
3.74 x 2.55
3.
3.73 x 3.16
3.89 x 2 81
3.84 x 3.30
4.04 x 2.92
4.
3.25 x 2.78
3.51 x 3.84
3.49 x 2.95
3.68 x 3.93
5.
3.51 x 2.82
3.44 x 3.28
3.63 x 2.97
3.47 x 3.38
6.
2.5 x 3.25
2.5 x 3.40
2.64 x 3.37
2.5 x 3.5
7.
2.3 x 3.31
3.15 x 2.4
2.52 x 3.42
3.27 x 2.6
8.
3.29 x 2.68
3.47 x 2.78
3.42 x 2.77
3.58 x 2.94
9.
3.2 x 2.3
2.8 x 2.7
3.5 x 2.64
3.07 x 2.9
10.
2.4 x 3.2
2.7 x 3.3
2.5 x 3.5
2.9 x 3.45
TABLE V:-. Considering an error of 0.5mm, 90% patients showed an statistically increase in size of the LPM after
treatment(p<0.01) thus indicating an decrease in atrophy after treatment.
12
E8Nilner M , Glenn C, Phyllis B , William S15, have
not included any diagnostic tool or physical parameter
to confirm the mechanism of action of the stabilizing
appliance except for the visual analogue scale to
evaluate the patients pain .Evaluating the efficiency of
the stabilization appliance only on the criteria on
patients pain is very subjective and does not actually
help in understanding the reason for decrease in pain
of the patient. Various authors like Glenn Clark et
al.9,10, Moody P M, Kemper J T11,16, Ronald A2 ,
Jeffery Okeson13 have proposed the purpose of the
stabilization appliance for providing stabilization to the
intracapsular structures of the TMJs , for distribution of
the occlusal forces and for reduction of the hyperactivity
of the masticatory muscles but no physical parameter
or diagnostic tool to explain the pathological finding
in the muscles of mastication and their response to
stabilization splint therapy was used.
Discussion:Thus the aim of the Part II of the study was to evaluate
the recovery changes in lateral pterygoid muscle in
TMD patients treated by stabilization splint, with the
help of MRI.
According to Glenn Clark et al.9,10, ,Moody P M,
Kemper J T11,12 Ronald A13 , Jeffery Okeson14 the
stabilizing appliance provides stabilization to the
intracapsular structures of the TMJ , to redistribute the
occlusal forces and to reduce myogenous pain by
decreasing the hyperactivity of the masticatory muscles
This Part II study was based on 10 patients suffering
from unilateral lateral pterygoid myalgia of a chronic
duration, selected from the Part I study. The aim of the
study was to evaluate the changes in LPM after
stabilization splint therapy. Patients with click were
excluded as stabilization appliance works best only
with muscle myalgia and not for clicking of the TMJ.A
hard acrylic stabilization splint was delivered to all the
patients and the patients were instructed to wear it part
time especially at night. Questionnaire in accordance
with Research Diagnostic Criteria was filled by the
patient and documented before treatment and after
every one month till the end of three months to access
the change in symptoms of the patients. After three
months an MRI evaluation of all the selected patients
was repeated and the changes in LPM on MRI before
appliance therapy and after appliance therapy was
compared by the same radiologist as in Part I.
Thus in this study MRI of the lateral pterygoid before
and after appliance therapy proved to be a good
diagnostic tool/physical parameter to evaluate the role
of stabilization appliance on decrease in painful
symptoms of patients suffering from muscle myalgia.
Muscle response to stabilization splint
therapy
On comparision with the MRI of the LPM before
treatment and 3 months after treatment, a significant
decrease in fatty degeneration was noted p<0.01.(Table
I).This decrease in fatty change was very significant in
one patient, significant decrease in 7 patients and
minimally significant in one patient.(Table II)(Fig 1)
(Fig 2) This decrease in fatty degeneration can be
attributed to the relaxation of muscle spasm and
increase in blood supply to the affected part resulting
in removal of the metabolic waste products and certain
alogogenic substances(eg bradykinin , prostaglandins)
which cause muscle degeneration and muscle pain.
The fatty degeneration had decreased in 90% of patients
but 10% patient had no change in the fatty degeneration
(Table I). The probable reason could be because the
patient had discontinued with the appliance after
reduction of painful symptoms and had worn it only
for 1 to 2 hours per day. A decrease in painful symptoms
even when there was no decrease in the amount of
fatty change was observed. This phenomenon can be
explained on the basis that the patient wore the
appliance only till the blood flow was increased in the
LPM and till all the alogogenic substances and
metabolic waste products could have been removed
which resulted in decrease in painful symptoms but
the appliance was not worn for enough time for the
healing to take place in the muscle.
With regards to the material of fabrication for an
stabilization splint ,soft acrylic was first proposed in
the early 1940.However , since its introduction there
have been mixed results on the effectiveness of
managing TMD symptoms with this type of material
for the fabrication of a stabilization appliance. (Clark
et al.9,10, Jeffery Okeson13).It has been demonstrated
that the soft material is not as effective in reducing TMD
symptoms as is a hard acrylic stabilization appliance
and it can contribute to inadvertent tooth movement
and occlusal changes. Thus in this study a hard acrylic
stabilization splint had been used.
Various studies by Raphael K, Marbach JJ1, Juan
Carraro, Raul Caffesse2 , Terry T ,Major A3 , Alex W4
, Ekberg E5 , Kuttila M et al6 , Ekberg EC, Vallon D,
Nilner M 7 Ekberg E, Nilner M 8 documents the
effectiveness of stabilization appliance in the reduction
of painful symptoms of TMJ, even though there is no
clear understanding of the physiologic mechanism of
the response to intraoral orthopedic appliance usage.
Various other studies by Alex W4, Kuttila M6, Le Bell,
Savolainen , Ekberg EC7, Vallon D, Nilner M , Ekberg
13
40% patients were suffering from severe fatty
degeneration and 60% of the patients had moderate
fatty degeneration before treatment.(Graph I)
also had a concomitant decrease in fatty
degeneration.(Table IV)On statistical evaluation it was
seen that the decrease in pain symptoms due to a
decrease in fatty degeneration was statistically
significant.(p value <0.01).Before appliance therapy,
60% of the patients had severe pain (7-10 on VAS) and
40% patients had moderate pain (3-6 on VAS)
(Graph II).
Severe group: - After treatment 75% of the above
patients had a decrease in fatty degeneration and
were then classified into moderate fatty degeneration
group whereas 25% of the above patients were
classified into minimal fatty degeneration group.
Severe group: - After appliance therapy 66.67 %
suffering from severe pain had a decrease in pain
symptoms and were having moderate pain and
33.33% patients had no pain(0 on VAS) after appliance
therapy.
Moderate group: - After treatment 83.33% of the
above patients had a decrease in fatty degeneration
and were classified into minimal fatty degeneration
group therapy whereas 16.67% patients had no change
in fatty degeneration.
Moderate group: - All the 40% patients that had
moderate pain (3-6 on VAS) before appliance therapy
had no pain (0 on VAS) after appliance therapy
Thus from the above results it has been seen that
stabilization appliance therapy does help in reduction
of fatty degeneration in the LPM.
Thus a significant amount of evidence exist that the
stabilization appliance helps in reduction of the fatty
degeneration in the LPM and this decrease in reduction
of the fatty degeneration results in a decrease in painful
symptoms of the TMJ.
Decrease in atrophy of muscle
As discusses above decrease in fatty change will result
in a decrease in atrophy of muscle. In the present study
on observations it was noticed that the length and height
of the LPM before and after treatment had changed.
(Table V).The size of the LPM had increased after
stabilization therapy. Mid level measurements were
taken to measure the size of the LPM, with the help of
the DICOM compliant software on the computer itself.
Considering a standard error of 0.5 mm any increase
than 0.5mm was considered as an increase in size of
the muscle. On statistical evaluation the increase in
size of the muscle was statistically significant( p value
<0.01).This increase in size of the muscle can be
explained due to a decrease in atrophy of the muscle
as already evident by the decrease in fatty degeneration
of the muscle. Thus a decrease in fatty degeneration as
well as an increase in size of the LPM, both are
suggestive of decrease in atrophy of the muscle. The
above observations gives evidence that the stabilization
appliance definitely helps in recovery of atrophy seen
in the LPM.
In our study after the use of stabilization appliances for
3 months we have been able to document the recovery
changes of the LPM with the help of MRI technique.
These observations of decrease in fatty degeneration
are well correlated with dramatic improvement in the
symptoms of pain in all the patients.
Currently a number of controversies exist about the
role of the stabilization splint in reduction of painful
symptoms of the TMJ. Marcelo Kreiner et al. 17,
Marcelo K, Edwin B, Glenn C18 stated that the
mechanism of action by which stabilization appliances
affect localized myalgia is not as medical devices but
work as behavioral measure the relation between the
decrease in pain and decrease in pathological changes
in the muscles. Therefore in this study evidence of
decrease in fatty degeneration as visible on MRI of LPM
with concomitant decrease in pain symptoms does not
agree with the conclusions of Marcelo Kreiner et al.17,
Marcelo K, Edwin B, Glenn C18 that the stabilization
appliance acts as a placebo effect. In our study MRI of
LPM has been a good physical tool to access the
pathologiocal changes in the LPM before appliance
therapy and the recovery changes after appliance
therapy.
Decrease in painful symptoms and fatty
changes after stabilization appliance
All the patients (100%) in this study after appliance
therapy showed a decrease in pain symptom as shown
by the Visual Analogue Scale.(Table IV) Decrease in
painful symptoms was statistically significant (p value
<0.01).90% of the patients also had an decrease in
fatty degeneration except for 10 % of patients who did
not have a decrease in fatty degeneration even though
he had a decrease in painful symptoms. Therefore 90%
of patients who had a decrease in painful symptoms
Conclusions:Three months after stabilization appliance therapy in
patients with lateral pterygoid myalgia, 90% patients
showed significant regression in fatty degeneration and
100% patients showed significant decrease in painful
symptoms. A clinically significant increase in size of
14
the muscle was also seen in 90% of the patients
indicating a decrease in atrophy of the muscle.
9)
References:1.
Raphael K, Marbach JJ. Evidenced based care of
musculoskeletal facial pain. Implications for the
clinical science of dentistry. J Am Dent Assoc.
1997;128:73-9.
2.
Juan Carraro, Raul Caffesse. Effect of occlusal splint
in TMJ sympotomology. J.Prosthet Dent.1978 ;
40:563-566.
3.
Terry T ,Major A.The Occlusal splint,An Adjunct
to Orthodontic treatment .J. Clin. Ortho. 1977;6
:383-390.
4.
Alex W.The effectiveness of an extreme canine
protected splint
in treatment of
Temporomandibular dysfunction Am J.
Ortho1995;107:229-234.
5.
6.
10). Glen T Clark .Nocturnal EMG evaluation of
myofacial pain dysfunction in patients undergoing
splint
therapy.J
Am
Dent
Associa.1979;99:607-611.
11). Okeson J P, Moody P M, Kemper J T .A study of
the use of occlusal splint in the treatment of acute
and chronic patient with Craniomandibular
disorders. J.Prosthet Dent.1982;48: 708-712.
12) Okeson J P, Moody P M, Kemper J T .Evaluation
of occlusal splint therapy and relaxation
procedures in patients with TMJ disorders.J Am
Dent Assoc.1983;107:420-424.
13) Ronald A. Intraoral Orthotic Therapy .Dent Clin
Nor Am 1997. 41;2 :309-322.
14) Jeffery
Okeson.
Management
of
Temporomandibular Disorders and Occlusion .
Edition 4 .Mosby Pub;1995.
Ekberg E.The efficacy of appliance therapy in
patients with Temporomandibular disorders of
mainly myogenous origin. A randomized control
short term trial. J. Orofacial Pain.2003;17: 133139.
15) Glenn C, Phyllis B , William S, John R. Nocturnal
masseter muscle activity and the symptoms of
masticatory disorder. J.Oral Rehabil. 1981; 8:279286.
Kuttila M , Le Bell, Savolainen E, Kuttila S , Alanen
P. Efficiency of occlusal appliance therapy in
secondary otalgia and Temporomandibular
disorders. Acta Odontol Scand. 2002 ; 60:
248-254.
7.
Ekberg EC, Vallon D, Nilner M. Occlusal appliance
therapy in patients with temporomandibular
disorders. A double-blind controlled study in a
short-term perspective. Acta Odontol Scand.1998;
56(2):122-8
8.
Ekberg E, Nilner M. A 6- and 12-month follow-up
of appliance therapy in TMD patients: a followup of a controlled trial. Int J Prosthodont. 2002;15
(6):564-70.
Glen T Clark. A critical evaluation of orthopedic
interocclusal appliance therapy, design theory and
effectiveness.J Am Dent
Associa.
1984;108:359-364.
16) Baragona B, Cohen H. Long term Orthopedic
Appliance Therapy.Dent Clin Nor Am.991; 35
:109-122.
17) Marcelo Kreiner,Edwin Betancor , Glenn
Clark.Occlusal Stabilisation appliance-Evidence of
their efficacy. J Am dent Associa.2001 ; 132:770778.
18) Glenn
C
,Occlusal
stabilization
appliances.Evidence of their efficacy.J Am Dent
Assoc. 2001;132:770-77l.
Fig 1 Fatty degeneration before treatment
15
Fig 2 Note decrease in fatty degeneration after stabilization appliance therapy
6
5
4
Before T/t
After T/t
3
2
1
0
Mild
Severe
Graph I:- Represents severity of fatty degeneration before treatment and after treatment
7
6
5
4
Pain beforeT/t
Pain after T/t
3
2
1
0
0
1 to 3
4 to 6
7 to 10
Graph II :- Represents severity of pain before T/t and after T/t .Pain was rated on Visual Analogue Scale.
16
“CEPHALOMETRIC EVALUATION BASED ON STEINER’S ANALYSIS
ON YOUNG ADULTS OF ASSAM”
Authors :
Dr. Nabanita Baruah, B.D.S.
Dr. Nabanita Baruah
Post graduate student
Department of Orthodontics
Regional Dental College, Guwahati
E-mail: [email protected]
Ph. No. : 09864091022
Dr. Mitali Bora, MDS, FICD (U.S.A.)
Professor and HOD
Department of Orthodontics
Regional Dental College, Guwahati
E-mail: [email protected]
Ph. No. : 09864032051
Dr. Mitali Bora
Abstract:
A cephalometric study of 70 Assamese young adults (35 male and 35 female) within age range of 18 – 25 years
with acceptable profile and occlusion was carried out by means of the Steiner’s analysis. The purpose of the study
was to establish skeletal & dental parameters for Assamese young adults using Steiner’s analysis, evaluation of
variability between male & female Assamese normal occlusion subjects and comparison of cephalometric norms
of Assamese population with the Caucasians as well as other non-Caucasian groups. Finally all the measurements
were computed statistically. Results showed that in comparison to the Caucasian samples the Assamese samples
were more protrusive skeletally and dentally with a greater tendency towards bimaxillary protrusion. These
differences indicate that fundamental variation exists in the craniofacial structure of Assamese and the Caucasians.
The results of the study support the fact that norms and standards of one racial group could not be used without
modification for other racial group and each different racial group would have to be treated according to its
individual characteristics.
Roentgenographic Cephalometrics was first
introduced as an armamentarium to study craniofacial
growth and development. Later on; it was being used
to study about facial form and its use gradually
extended to development of cephalometric norms to
define the objectives of orthodontic treatment. The
introduction of the cephalometer then started providing
avenues for creation of cephalometric analysis for
clinical diagnosis and treatment planning and soon the
cephalogram became an indispensable weapon in the
armory of an orthodontist for correct diagnosis,
treatment planning, prognostic evaluation and
comparative studies. The Cephalometric norms for
Caucasians for many decades were being applied on
the population groups all over the world. But with time
many investigator’s concluded that there was variation
of the craniofacial morphology between different ethnic
groups.
various cephalometric analyses were not sufficient to
apply to different racial or ethnic groups Cephalometric
studies on different ethnic groups including those of
Chan’s on Chinese, Garcia’s on Mexican Americans,
Drummond’s on Negroes & Park’s on Korean adults
have indicated that normal measurements of one group
cannot be considered normal for other racial groups.
Investigators such as fujio Miura in Japan, and Carlos J
Garcia in USA. have established their norms on the
basis of Steiner’s analysis. The first cephalometric study
on the Indian population was done by Kotak on
Gujrathi girls and thereafter Nanda, John and Valiathan,
and others have done cephalometric studies on various
population groups of India.
But till date no study has been conducted on the
population of Assam. It was therefore thought pertinent
to undertake such a study for young population of
Assam and observe various hard tissues cephalometric
values by means of Steiner’s analysis with a view to
clinical application of the findings.
Thus it became apparent that the widely studied
Caucasian norms which were established by using
17
cephalogram was traced twice and the average
measurement taken into account to minimize the error.
AIM AND OBJECTIVES
The following objectives are accomplished by this
study.1) Establishment of skeletal & dental parameters
for Assamese young adults using Steiner’s analysis. 2)
Evaluation of variability between male & female
Assamese normal occlusion subjects. 3) Comparison
of cephalometric norms of Assamese population the
Caucasians and other groups. Finally all the
measurements are computed statistically.
The linear measurements were recorded with a
measuring scale up to 0.05mm correction. The angular
measurements were recorded with a protractor up to
0.05mm correction. Statistical calculations performed
included mean, standard deviation, standard error and
student’s‘t’ test for each parameter. Statistical
comparisons were done by the‘t’ test.
The mean values of this study had been compared with
the Steiner’s norms for Caucasian Subjects. On the basis
of this data, a complete chart of the STEINER’S
ANALYSIS was established for Young Assamese adult
population.
MATERIALS AND METHOD
The material for this study consisted of standardized
lateral head roentgenograms of 35 Assamese young
boys and 35 girls residing in Guwahati. They were
selected as per the following criteria.
A normal acceptable and pleasing profile, Age 18-25
years of age, Angle Class I molar relationship with full
complement of erupted teeth up to 2nd molar in proper
intercuspation, No history of orthodontic treatment,
gross carious lesion and periodontal disease and no
history of facial trauma.
A panel was formed to check the samples required for
the study and they gave their consent regarding the
fulfillment of the criteria of the samples
Photograph showing Cephalometric Head Plate.
Landmarks used in the study
ANGULAR MEASUREMENTS: Angle SNA, SNB, ANB,
SND, Maxillary I to NA. Mandibular I to NB, Maxillary
I to Mandibular I, Occlusal Plane to SN, Go-Gn to SN.
LINEAR MEASUREMENTS (mm): Maxillary I to NA line,
Mandibular I to NB line, Pog to NB Line, SL Line and
SE Line.
The subject’s head was positioned in the Pantos 16 xp
roentgenographic cephalostat maintaining a target-film
distance of 5 feet or 152.4 cms. The PSP plate which is
enclosed in a light tight cassette was positioned parallel
to the midsagittal plane of the subject such that the
X-ray beam was directed perpendicular to it. The ear
rods were used to stabilize the head in a vertical plane.
The subject’s head was positioned so that the Frankfort
Horizontal plane would be parallel to the floor and
was instructed to look straight and maintain a relaxed
posture with teeth in centric occlusion during the
exposure of the films. The kilo voltage used for X-ray
exposure was 61-85 Kvp. Milliamperge was 4-10 mA
and time required for the exposure was 2.5 seconds.
A male subject’s head positioned in the Cephalostat.
(Lateral View)
The lateral cephalogram were traced upon an A4 size
Acetate matt tracing sheet with a 3HB hard lead pencil
over a well-illuminated viewing screen. Each
A female subject’s head positioned in the
Cephalostat. (Frontal View)
18
The results are shown in the following tables :
TABLE 2 : COMPARISONS BETWEEN THE MEAN ANGULAR AND LINEAR PARAMETERS
OF 35 MALE AND 35 FEMALE ASSAMESE SUBJECTS
Sl. No.
Parameters
Male
Female
Significance
Average
S.D.
S.E.
Average
S.D.
S.E.
‘t’ value
‘p’ value
1
< SNA°
84.86
3.29
0.56
84.14
2.91
0.49
0.96
NS
2
< SNB°
81.31
3.64
0.61
81.51
2.99
0.51
0.251
NS
3
< ANB°
3.37
1.29
0.21
2.65
1.47
0.25
2.15
P< .05
4
< SND°
78.66
3.13
0.53
78.68
2.97
0.50
0.04
NS
5
< SN-GoGn°
26.23
3.88
0.66
26.97
5.82
0.98
0.63
NS
6
< Sn-Occ°
12.83
3.52
0.59
14.43
4.02
0.68
1.77
P< 0.05
7
< I To NA°
25.4
4.53
0.77
24.68
6.01
1.02
0.71
NS
8
<T To NB°
29.94
6.27
1.06
28.57
6.24
1.05
0.92
NS
9
< I To 1 °
121.4
7.88
1.33
124.03
9.21
1.56
1.28
NS
10
I To NA (mm)
4.03
1.79
0.30
4.2
1.79
0.30
0.39
NS
11
T To NB (mm)
5.11
1.98
0.33
4.14
2.36
0.39
1.86
P<0.05
12
SE
(mm)
22.26
3.48
0.59
19.68
1.84
0.31
3.88
P<0.001
13
SL
(mm)
54.77
5.52
0.93
51.57
2.26
0.38
3.17
P<0.01
14
Pog-NB
(mm)
2.66
1.26
0.21
2.00
2.32
0.39
1.48
NS
N.S. = Not significant (P>0.05)
P<0.05 = Significant at 5% level P<0.01 = Significant at 1% level P< 0.001 = Significant at 0.0 1% level.
TABLE 4: COMPARATIVE STATISTICAL EVALUATION OF STEINER’S NORM AND THE PRESENT STUDY
Sl. No
Parameters
Caucasian
Norms
Assamese Sample (N=70)
Statistical Evaluation
Mean
S.D.
S.E.
‘t’ value
d.f.=69
‘P’ value
1
<
SNA°
82
84.5
3.11
0.37
6.76
P<0.05
2
<
SNB°
80
81.41
3.31
0.30
4.67
P<0.05
3
< ANB°
2
3.01
1.42
0.17
5.94
P<0.001
4
< SND°
76
78.67
3.06
0.37
7.22
P<0.001
5
< SN- GoGn°
32
26.6
4.93
0.59
9.15
P<0.001
6
< Sn -Occ°
14
13.63
3.83
0.46
22.5
P<0.001
7
< I To NA°
22
25.04
5.30
0.63
4.83
P<0.001
8
< T To NB°
25
29.26
6.25
0.75
5.68
P<0.001
9
< I To T°
131
122.71
8.61
1.03
8.05
P<0.001
10
1 To NA linear
(mm)
4
4.11
1.78
0.22
0.5
NS
11
T To NB Linear (mm)
4
4.63
1.97
0.24
2.63
P<0.05
12
SE
(mm)
22
20.97
3.64
0.15
2.34
P<0.05
13
SL
(mm)
51
53.17
6.65
0.44
2.71
P<0.05
14
Pog-NB
(mm)
2.33
1.27
0.80
N.S = Not significant (P>0.05) P<0.05= Significant at 5% level
P<0.01= significant at 1% level P<0.001 = significant at 0.01% level.
19
TABLE 5: COMPARISON OF CEPHALOMETRIC VALUES OF PRESENT STUDY (ASSAMESE POPULATION),
WITH CAUCASIANS, JAPANESE, ISRAELI, NEGROES, KOREANS AND MEXICAN AMERICANS USING
STEINER’S REFERENCE NORMS
Sl. No.
Cephalometric analysis Caucasian Present study
Japanese
Steiner
(Assamese
(Miura et a.)
Population)
Israeli
(Ruth
Gleis,
et al.)
Negroes
Korean
Mexican(Richard
(In-Chool Americans)
A.Drummond) Park. et al) (C.J. Garcia)
1
< SNA°
82
84.5
81.3
81.63
84.7
81.15
83.6
2
< SNB°
80
81.41
76.8
78.2
79.2
78.7
80.8
3
< ANB°
2
3.01
4.5
3.43
5.5
2.5
2.8
4
< SND°
76
78.67
73.4
75.31
75.8
75.8
77.3
5
< SN-GoGn°
32
26.6
36.2
34.63
38.2
33.4
31.1
6
< Sn-Occ°
14
13.63
20
17.68
16.9
15.8
7
< 1ToNA°
22
25.04
24.1
23.8
24.1
23.4
20.5
8
< TToNB °
25
29.25
31.2
28.46
36.7
27.4
26.7
9
<TTo 1°
131
122.71
120.3
124.34
113.8
126.55
130
10
1 To NA linear (mm)
4
4.11
5.9
5.2
7.4
7
5.5
11
T To NB Linear (mm)
4
4.63
7.8
6.46
11.4
7.2
5.7
12
SE
(mm)
22
20.97
21
21.3
13
SL
(mm)
51
53.17
41.1
53.9
14
Pog-NB
(mm)
2.33
0.43
5.38
1.8
0.9
The mean for the various cephalometric values of Steiner’s analysis.
Richard A Drummond: Mean values for 40 Negro samples.
Present study: Mean values for 70 Assamese samples.
Miura et al: Mean values for 90 Japanese samples.
In Chool Park et al: Mean values for 80 Korean samples.
Ruth Gleis et al: mean values for 40 Israeli samples.
Garcia: Mean values for 59 Mexican-American samples.
TABLE 6: COMPARISON OF CEPHALOMETRIC VALUES OF PRESENT STUDY (ASSAMESE POPULATION), CAUCASIAN
AND OTHER INDIAN RACES USING THE STEINER‘S REFERENCE NORMS
Sl. No.
Cephalometric
analysis
SNA°
CAUCASIAN
STEINER
PRESENT
STUDY
(ASSAMESE)
KERALA
(JOHN K.K)
INDIAN
RESIDENTS IN
U.S.A
(VALIATHAN A)
KARNATAKA
(SAVADI.S.C)
HARYANA GUJARATHIS
(Late Dr
PATEL.H.M.
V.K. Grover
et.al)
et. al)
82
84.5
84.14
81.77
83.45
82.78
81.26
1
<
2
< SNB°
80
81.41
81.85
77.9
80.50
79.6
78.25
3
< ANB°
2
3.01
2.27
4.32
2.95
3.18
3.01
4
< SND°
76
78.67
79.36
75.6
77.85
5
< SN-GoGn °
32
26.6
27.91
29.35
29.01
6
< Sn-Occ °
14
13.63
11.79
15.97
7
< 1To NA°
22
25.04
27.44
22.85
8
< T To NB°
9
<TTo 1 °
10
I To NA ( mm)
11
T-NB
4
12
SE
(mm)
22
13
SL
(mm)
51
53.17
59.66
14
Pog-NB (mm)
2.32
1.06
(mm)
25.85
75.6
26.34
29.06
14.36
15.7
23.75
25.34
25
29.26
30.75
33.12
28.45
28.01
30.67
131
122.71
119.69
119
122.95
123.97
120.63
4
4.11
7.46
7
6.65
5.21
6.48
4.63
7.5
8.9
6.85
6.48
20.97
21.46
The mean for the various cephalometric values of Steiner’s analysis.
Present study: mean values for 70 Assamese samples.
John. K. K: mean values for 50 samples from Kerala.
Valiathan: mean values for 20 Indian residents of U.S.A Samples.
12.40
57.40
2.25
7.13
20.6
51.7
2.13
Savadi S.C: mean values for Karnataka samples
Late Dr V.K. Grover et al: Mean values for 100 Haryana samples.
Patel. H.M et al: Mean values for 30 Gujrathi samples.
20
DISCUSSION
Dental
The present study tries to establish a norm or standard
for the skeletal and dental pattern of Assamese young
adults according to Steiner’s Analysis. The results were
compared with the Steiner’s norm for the Caucasians
samples. A comparison was also made between the
values of the various parameters with other population
groups and also Indian population groups as studied
by various Indian workers. Cephalometerically nine
angular and five linear measurements were used by
Steiner. The Steiner’s parameters on Caucasian samples
have been taken from Cecil.C Steiner’s original article
“Cephalometrics for you and me” published in the
American Journal of orthodontics, October (1953). The
present study revealed that the mean values for the
Assamese sample were significantly different in all
measurable values from the means of Steiner’s analysis
of Caucasians.
The dental measurements except for the linear value
of Mx I to NA, rest of the parameters were significantly
different. Angle I to NA, mandibular I to NB, (both
angular and linear) recorded a greater value for the
Assamese subjects These findings along with a more
acute interincisal angle of the Assamese young adults
demonstrated the fact that the upper & lower incisors
of Assamese subjects were more procumbent &
protracted when compared with that of Caucasian
subjects. As far as the comparison between male and
female subjects was concerned, except for the linear
measurement of mandibular I to NB, rest of the
parameters namely I to NA ( angular and linear), Angle
I to NB, Angle I to I and I to NA, (linear) did not bear
any statistically significant difference.
This study also suggested wide divergence in the SE
distance in the Assamese population. Mean SE distance
being less than that of Steiner’s value as well as that of
other researchers. This study also depicted that the
anteroposerior length of the mandible in relation to
the cranial base was larger in Assamese sample than
Caucasians. Both SL & SE distance depicted a
statistically significant difference between male &
female subjects with a value of P <0.001 respectively
Skeletal; Evaluating Angle SNA and SNB it is interesting
to note that the Maxillary and the Mandibular apical
base in the Assamese population were more prognathic
(PL<. 05) when compared to Caucasians. But there was
no statistically significant difference between male and
female Assamese population.
In Assamese samples, the mean value of bony chin
position in relation to the NB plane (Pog to NB) was
2.33mm; with a S.D. of ± 1.27 mm. Steiner remarked
that this value was less important because the pogonion
was influenced greatly by growth. So he did not
establish any reference norm for this parameter. There
was statistically no significant difference between the
male (2.66 mm ± 1.26 mm) and female (2.00 mm
± 2.32 mm) Assamese subjects.
Angle ANB which is the most common indicator to
determine the relative positions of the upper and lower
jaws to each other showed an increased value than
the Caucasians which meant a greater tendency
towards bialveolar protrusion (P< .001). There was
significant difference in the ANB value between male
& female Assamese subjects. (P < .05),
The Mean value of Angle SND was more in Assamese
subjects indicating that the position of the centre of
the symphysis was placed more forwards than the
Caucasian sample. On comparison between male &
female Assamese subjects it was seen that there was
no significant difference between them.
Summary and Conclusion
In view of the findings of the current study it is evident
that in the Assamese population with so called well
balanced faces, there are some fundamental variations
in the craniofacial structure of Asamese when
compared with Steiner’s norms. These should be
established to serve in the diagnosis and treatment of
the Assamese patients. The results of the present study
also support the view that a single standard of facial
esthetics should not be supplied to all racial and ethnic
groups. The following differences and similarities were
demonstrated in the Assamese samples as compared
to the Caucasian samples
The Mandibular plane to the cranial base plane of
Assamese adults revealed that the angle was smaller
than the Steiner’s norm. From this study it can be said
that the Assamese group pattern exhibited a more
horizontal growth pattern than the Caucasians. The
study recorded that there was no significant difference
in the mean values between the male boys & girls.
Assamese population showed a lesser inclination of
occlusal plane (13.63,) than the Caucasians (p<0.001)
and this study also exhibited marked variation between
male & female subjects.
1. The antero-posterior position of the apical base of
the maxilla and mandible in relation to the anterior
cranial base was more anteriorly placed or
21
prognathic as compared to the Caucasian samples.
An increased ANB angle indicated a greater
tendency towards bialveolar protrusion.
6.
Kotak VB.Cephalometric evaluation of Indian girls
with neutral occlusion. Journal of All Indian Dental
Association. Vol 36, 183-187, 1961
2. The angular relationship of the mandibular plane
in relation to the cranial base plane (SN-GoGn
angle) was smaller which was suggestive of a strong
horizontal growth pattern in the Assamese.
7.
Nanda R, Nanda RS. Cephalometric study of the
dentofacial complex of North Indians. The Angle
Orthodontist.Vol 1, 22-28, 1969.
8.
John KK, Valiathan SS, Sundram KR.
Cephalometric profile of Aryodravidians study of
denture bases. Journal of Indian Orthodontic
society. Vol 20:84-94.1989
4. Study suggested wide divergence of the SE and SL
distance in the Assamese population when
compared to the Caucasians.
9.
Steiner C.C. Cephalometrics for you and me.
American Journal of orthodontics Vol 39, No10:
729-755. 1953.
The study concluded that most of the cephalometric
measurements of the Assamese subjects were
significantly different from the Steiner’s Caucasian
samples and also from other ethnic groups because
the various published methods represent population
averages, it is important to consider each patient’s
treatment goals and needs during evaluation and
treatment planning.
10. Steiner C.C. Cephalometrics in Clinical practice,
The Angle Orthodontist Vol29, No1:8-29, 1959.
3. The Assamese population has a protrusive
alveodental pattern when compared to the
Caucasians.
11. Steiner C.C. The use of cephalometrics as an aid
to planning and assessing orthodontic treatment.
American Journal of orthodontics Vol. 46, No.10:
Page 721-754, 1960.
12. Dr K Jyothindra Kumar, A Handbook of
Cephalometric norms for use with Indian
population, Indian orthodontic society.
To draw a decisive conclusion of the Steiner‘s analysis
on Assamese population for diagnosis, treatment
planning and prognostic evaluation further study should
be done on greater number of samples after proper
screening of facial types.
13. Ruth Gleis, Naphtali Brezniak,and Myron
Lieberman. Israeli Cephalometric standards
compared to Downs and Steiner analyses The
Angle Orthodontist, No. 1, 35 - 41: 1990.
REFERENCES
1.
Broadbent BH. A new X- Ray technique and its
application to Orthodontia. The Angle
Orthodontist, Vol 1, No 2: 45-6.1931.
2.
Garcia C.J. Cephalometric evaluation of Mexican
Americans using the Downs and Steiner’s analyses.
American Journal of Orthodontics Vol 68, No
1:67-74. 1975.
3.
4.
5.
14. Late Dr V.K. Grover, Dr. Vijay Rani Grover, Dr.
Ravindra Kumar Bhutani.Hard tissue
cephalometric observations based on Steiner’s
analyses in young adults in Haryana. Journal of
Indian Dental Association, Vol 69, July 1998.
15. Nasser M.Al-Jasser. Cephalometric evaluation of
craniofacial variation in normal Saudi population
according to Steiner’s analysis. Saudi Medical
Journal: Vol21, No 8,746-750, 2000.
Drummond, R.A. A determination of
Cephalometrics norms for the Negro race.
American Journal of Orthodontics 54: 670-682.
1968.
16. Ali H. Hassan. Cephalometric Norms for Saudi
Adults Living in the Western Region of Saudi
Arabia. The Angle Orthodontist: Vol. 76, No.
1,109–113.2005.
Park IC, Doughlas, Bowman, Lewis Clapper. A
cephalometric study of Korean Adults. American
journal of Orthodontics & dentofacial orthopedics
vol. 96, no. 1, 54-59.1989.
17. Emmanuel Olubusayo Ajayi. Cephalometric
norms of Nigerian children. American Journal of
orthodontics and Dentofacial orthopedic 128:653100. July 2005.
Miura Fujio, Inone N, and Suzuki K.
Cephalometric standards for Japanese according
to the Steiner analysis. American Journal of
Orthodontics 51:288-295, 1965.
18. Athanasios E Athanasios, Orthodontic
Cephalometry, Mosby-Wolfe, London, 1995.
22
ORTHO-SURGICAL MANAGEMENT OF CLASS III MALOCCLUSION
IN IDENTICAL TWINS — CASE REPORT
Authors:
Dr. Nandini V. Kamat, M.D.S. - (Assistant Professor)
Dr. Pavan Kumar Chandra, M.D.S., M.D.Sc. - (Professor & Head)
Dr. Anar Timble, M.D.S. - (Senior Resident)
Dr. Aldrin Godinho, M.D.S. - (Ex Post Graduate Student)
Department of Orthodontics & Dentofacial Orthopedics,
Goa Dental College & Hospital,
Bambolim, Goa
Dr. Nandini V. Kamat
Corresponding author:
Dr. Nandini V. Kamat
10- By the bay, Landscape project,
Caranzalem, Goa 403 002
E-mail: [email protected]
Mobile number: 09326119440
Residence number: 0832 2464186
Abstract:
Management of identical twins with ortho-surgical approach remains a challenging task. While planning treatment,
it is very important to take great care to execute proportional treatment plan so as to produce identical phenotypes
post-surgically.
These case reports describe management of two 18 year old identical twins with class III malocclusion which
exhibited both maxillary retrusion and mandibular prognathism. Dental examination revealed severe cross bite,
mild open bite and severe rotations. As far as dentition was concerned twins showed mirror image variations i.e.
reverse asymmetric features.
A combination of Arnett’s clinical and soft tissue cephalometric examination was used to diagnose and plan the
treatment for facial changes. While planning treatment maxillary advancement was not considered as patients
had a decreased nasal projection. Appropriate pre-surgical orthodontics was followed by bilateral sagittal split
osteotomy for mandibular setback. This was followed by short phase of post-surgical orthodontics. Ideal overjet
and overbite was established and esthetic results were pleasing. Both the twins were evaluated two years post
surgery and results were found to be stable.
presented with severe class III malocclusion had a
parent with the same problem, and one sixth had an
affected sibling. Naini et al6 found that the concordance
for anteroposterior and vertical facial parameters was
greater in monozygotic twins than in dizygotic twins.
Introduction:
Diagnosis remains the cornerstone in the management
of any orthodontic problem. There has been a paradigm
shift in the diagnostic process. It is no longer occlusion
centric. Positions and lengths of all components; soft
tissue, bone and teeth in all three dimensions can be
evaluated. One of the most efficient tool in an
orthodontists’ diagnostic armamentarium remains
Arnett’s1,2,3,4 clinical and cephalometric facial and
dental planning.
The prognosis of early treatment in severe class III
malocclusion remains controversial. In adult patients
who present with full fledged class III malocclusion,
combined ortho-surgical management remains the only
option.
The role of heredity in the etiology of skeletal class III
malocclusion is well established. Litton et al5 in their
study found one third of a group of children who
Long term follow up is essential in patients with
mandibular setback surgery. Relapse may be due to
faulty planning, faulty surgery or postsurgical growth.
23
Mobarak et al7 assessed long term changes in soft tissue
profile following mandibular setback surgery and
deduced that mandibular setback surgery is a stable
procedure and that most of the relapse if at all, takes
place in first six months after the surgery.
Diagnostic summary was skeletal class III with a small
maxilla, severely protrusive mandible, average growth
pattern, anterior cross bite, mild open bite, spacing and
individual tooth malpositions like rotations.
Etiology in these cases seemed to have a strong genetic
component.
Bailey et al8 evaluated long term soft tissue changes
after orthodontic and surgical corrections of skeletal
class III malocclusions and concluded that class III
patients are less stable during first year after surgery
but show fewer changes in hard and soft tissue
measurements beyond that point.
Treatment objectives:
1. Attain a pleasing profile by improving the
relationships of jaw bases while maintaining
identical phenotype.
Diagnosis and Etiology:
2. Correction of crossbite and open bite,
Two 18 year old identical twin sisters reported to our
department with the chief complaint of protruding
lower jaw. Although this article describes two case
reports, the two have been described together with the
differences if any, being pointed out. The twin sisters
have been referred to as Twin-1 (Fig.1) and Twin-2
(Fig.2).
3. Correction of individual tooth rotations.
4. Adequate torque for maxillary and mandibular
incisors.
Treatment alternatives:
Only orthodontic treatment with extractions of lower
premolars would not have addressed patients’ chief
complaint about facial esthetics. Also there was a possibility
of periodontal damage to the mandibular incisors.
The patients were healthy and no signs and symptoms
of temporomandibular disorder were noted.
Clinical frontal examination revealed a symmetric face,
though Twin1 showed positional asymmetry and more
fullness on the right side than the left and Twin2 showed
more fullness on the left side than the right which
disappeared while smiling. Vertical assessment of the
face showed a midface which was smaller. Within the
lower face, upper lip appeared shorter compared to
the lower lip.
Surgical option had two possibilities-Two jaw surgery
that is maxillary advancement and mandibular setback
versus only mandibular setback.
Single jaw surgery that is mandibular setback was
chosen for the following reasons:
• Magnitude of severity was more in the mandible
than in the maxilla
Clinically, profile view showed a concave profile with
mildly deficient midface, small nose, adequate
nasolabial angle, severely protruded lower lip, flat
mentolabial sulcus and adequate throat contour
without sag.
• Decreased nasal projections limited maxillary
advancement
• Both surgeries were planned one after another with
a gap of one month and to minimize hospital stay
and other complications for the parents of the twins,
comparatively simple procedure of single jaw
surgery was chosen.
Dental examination revealed class III molar and canine
relationship, anterior cross bite, mild open bite and
individual tooth malpositions. (Fig.3 & 4). In twin-1,
mandibular midline was shifted to right by 1.5mm and
in twin-2, mandibular midline was shifted to left by
1.5mm. Dentitions in twin sisters showed mirror image
variations, also referred to as situs inversus (Fig.5).
• Maxillary and mandibular width match was
achievable with single jaw surgery
Treatment plan:
Though cephalometric comparisons between twins
showed minor differences, inferences were similar
(Fig.6 & 7, Table-1 a&b and Table-2 a&b). The
cephalometric evaluation showed a small maxilla,
protrusive mandible and an average growth pattern.
Maxillary incisors were proclined and mandibular
incisors showed slight retroclination. Fig.8 and 9 show
pre-treatment panoramic radiographs of Twin-1 and
Twin-2 respectively.
A pre-surgical phase of orthodontic treatment was
essential to align the arches and to improve torque of
maxillary and mandibular incisors.
Bilateral sagittal split osteotomy was planned for 5 mm
of mandibular setback which was to be followed by
short phase of post-surgical orthodontics to achieve
final desired tooth interdigitation.
24
chewing, no pain in the temporomandibular joint and
stability of the results. All the above criteria could be
met in both these cases. When the twins were
evaluated, long term treatment results were stable.
Treatment progress:
The pre-surgical phase was initiated with 022 preadjusted edgewise appliance. The maxillary and
mandibular arches were aligned using .016 NiTi arch
wires which were followed by progressive heavy arch
wires like .016 SS, .018 SS, .017x.025 S/S wires. Final
wires prior to surgery were .019x.025 S/S.
Treatment of monozygotic twins and that too with
ortho-surgical approach was a learning experience for
our team. In identical twins, alikeness is part of their
identity. Orthognathic surgery has a profound impact
on the function and appearance of the patient which
could easily create post-operative psychological and
behavioral imbalance in the identical pair.
In twin-1 (Fig.10) arches were well aligned and
maxillary and mandibular incisor torque values were
close to ideal. In twin-2 (Fig.11) alignment and arch
coordination was good but torque values could have
been improved.
It is important to plan surgeries with predictable
outcomes so as to create similar phenotypic appearance
post-surgically. Mandibular setback surgery has
predictable outcomes and long term follow up of the
twins showed similar phenotypic appearance postsurgically
A bilateral sagittal split osteotomy was performed to
setback the mandible by 5 mm in both twins. Rigid
fixation was used to stabilize the mandible (Fig.12)
In the post-surgical phase final detailing was done using
.014 S/S wires and settling elastics. Figs. 13 through 16
show illustrations of post-surgical radiographs and
photographs.
It was gratifying to see the change in twin sisters’ self
perception and increased levels of confidence at the
completion of treatment.
Treatment results:
Acknowledgements:
Most of the treatment objectives were achieved. There
was a marked improvement in facial esthetics; anterior
cross bite and open bite were corrected. Both maxillary
and mandibular arches were properly aligned and
canine and molar class I relationship was achieved in
twin-1. In twin-2, esthetic goals were achieved but
relapse of a de-rotated maxillary right canine was noted
post de-banding. This rotation was corrected with semifixed appliance.
The author would like to acknowledge Dr. Vikas
Dhupar and his team from the department of Oral &
Maxillofacial Surgery, Goa Dental College & Hospital,
who performed the surgeries and also Dr. Yashodhan
M. Bichu & Dr. Kamna Srivastava for their help in
compilation of the manuscript.
References:
1. Arnett GW, Bergman RT. Facial keys to orthodontic
diagnosis and treatment planning. Part I Am J Orthod
Dentofacial Orthop 1993;103:299-312.
Long Term Evaluation:
Long term assessment is essential in mandibular setback
surgery. Relapse may be due to faulty planning, faulty
surgery, postsurgical growth or aging changes.
2. Arnett GW, Bergman RT. Facial keys to orthodontic
diagnosis and treatment planning. Part II Am J
Orthod Dentofacial Orthop 1993;103:393-411.
Both twins were evaluated two years post-surgically
and showed stable results. (Fig.17 & 18).
3. Arnett GW, Jelic JS, Kim J, Cummings DR, Beress
A, Worley CM, Chung B, Bergman R. Soft tissue
cephalometric analysis : Diagnosis and treatment
planning of dentofacial deformity. Am J Orthod
Dentofacial Orthop 1999;116:239-253.
Fig.19 & 20 illustrate the cephalometric
superimpositions at pre-treatment, post-surgery and at
two year follow up.
Discussion and conclusion:
4. Bergman RT. Cephalometric soft tissue facial
analysis. Am J Orthod Dentofacial Orthop
1999;116:373-389.
Facial balance and harmony could be achieved in these
twin sisters because of combined ortho-surgical
approach. Clinical success after orthognathic therapy
can be defined as a combination of following factors:
patient (and patient’s family) satisfaction, correct static
and functional occlusion, patient comfort when
5. Litton SF, Ackermann LV, Isaacson RJ, Shapro BL.
A genetic study of class III malocclusion. Am
J Orthod Dentofacial Orthop 1970;58:565-577.
25
6. Naini F, Moss J. Three dimensional assessment of
relative contribution of genetics and environment
to various facial parameters with the twin method.
Am J Orthod Dentofacial Orthop 2004;126:
655-665.
8. Bailey LT, Dover AJ, Proffit WR. Long term soft tissue
changes after Orthodontic and surgical correction
of skeletal class III malocclusion. Angle
Orthod.2007;77(3):389-396.
7. Mobarak KA, Krogstad O, Espeland L, Lyberg T.
Factors influencing the predictability of soft tissue
profile changes following mandibular setback
surgery. Angle Orthod. 2001;71(3):216-227.
9. Hudson J, Jaffrey BJ, Davis C, Witkowski CE. The
psychological and behavioral considerations of
orthognathic surgery on identical twins. Oralsurg
Oralmed Oralpath.1989;68(30);259-263.
Fig. 1: Pre-treatment Extra oral photographs of twin-1.
Fig. 2: Pre-treatment Extra oral photographs of twin-2.
Fig. 3: Pre-treatment Intra oral photographs of twin-1.
26
Fig. 4: Pre-treatment Intra oral photographs of twin-2.
Fig. 5: Situs inversus in identical twins.
Fig. 6: Pre-treatment Lateral Cephalogram of twin-1
Fig. 7: Pre-treatment Lateral Cephalogram of twin-2.
Fig. 8 Pre-treatment Panoramic radiograph of twin-1.
Fig. 9 Pre-treatment Panoramic radiograph of twin-2.
27
Fig. 10 Pre-surgical photographs of twin-1.
Fig. 11 Pre-surgical photographs of twin-2.
Fig. 12: Mandibular setback surgery.
28
Fig. 13-a: Post-surgical Extra oral photographs of twin-1.
Fig. 13-b: Post-surgical Intra oral photographs of twin-1.
29
Fig. 14-a: Post-surgical Extra oral photographs of twin-2.
Fig. 14-b Post-surgical Intra oral photographs of twin-2.
30
Fig. 15: Post-surgical Lateral cephalogram & panoramic radiograph of twin-1.
Fig. 16: Post-surgical Lateral cephalogram & panoramic radiograph of twin-2.
31
Fig.17: Long term assessment of twin-1 two years post surgery.
32
Fig.18: Long term assessment of twin-2 two years post surgery.
33
Fig. 19: Cephalometric superimposition of twin-1.
(Blue: Pre-treatment, Red: Post-surgical, Green: Two
years post-treatment)
Fig. 20: Cephalometric superimposition of twin-2.
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NORMS
FOR FEMALES
Table 1-a: CEPHALOMETRIC SUMMARY FOR TWIN-1
CEPHALOMETRICS FOR ORTHOGNATHIC SURGERY COGS- HARD TISSUE ANALYSIS
MEASUREMENTS &
LANDMARKS
CAUCASIAN
NORMS FOR
VALUES
PRETREATMENT
VALUES
PRETREATMENT
VALUES
POSTTREATMENT
VALUES
Cranial Base
Ar-Ptm (|| to HP)
37.1 ±2.8
32
31.5
31.5
Ptm-N (|| to HP)
52.8 ±4.1
49
49
49
N-A-Pg(Angle)
3.9O ± 6.4
-10 O
-10 O
-4 O
N-A (|| to HP)
0.0 ±3.7
0
0
0
N-B (|| to HP)
-5.3 ±6.7
+7
+5
+2
N-Pg (|| to HP)
-4.3 ±8.5
+10
+7.5
0
N-ANS (⊥ HP)
54.7 ±3.2
47
48
48
ANS-Gn (⊥ HP)
68.6 ±3.8
67
70
70
PNS-N (⊥ HP)
53.9 ±1.7
50
50
50
Horizontal (skeletal)
Vertical (skeletal + dental)
O
O
MP-HP (Angle)
23 ±5.9
1 –NF (⊥ NF)
30.5 ±2.1
1-MP (⊥ MP)
45 ±2.1
6-NF (⊥ MP)
6-MP (⊥ MP)
27
O
29
O
29 O
27
28
28
36.5
37
38
26.2 ±2.0
25
25
25
35.8 ±2.6
28
30
30
PNS-ANS (|| to HP)
57.7 ±2.5
50
50
50
Ar-Go (linear)
52.0 ±4.2
49
49
49
Go-Pg (linear)
83.7 ±4.6
78
77.5
74.5
B-Pg (|| to MP)
8.9 ±1.7
+7
+7
+7
Maxilla, Mandible
Ar-Go-Gn (Angle)
O
119.1 ±6.5
130
O
132
O
132 O
Dental
OP Upper-HP (Angle)
6.2 O±5.1
2O
A-B (|| to OP)
-1.1 ±2.0
-7
1 –NF (Angle)
O
111 ±4.7
129
1-MP (Angle)
95.9O±5.2
92 O
35
6O
5O
-6.5
O
120
O
91 O
-2
120 O
92 O
36
Table 1-b: CEPHALOMETRIC SUMMARY FOR TWIN-1
ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS (STCA)
PARAMETER
CAUCASIAN
NORM FOR
FEMALES
PRETREATMENT
VALUE
PRESURGICAL
VALUE
POSTTREATMENT
VALUE
Dentoalveolar Factors
Maxillary occlusal plane to TVL
95.6 ± 1.8
92 O
92 O
93 O
Mx1 to Mx occlusal plane
56.8 ± 2.5
43
52
52
Md1 to Md occlusal plane
64.3 ± 3.2
70
67
67
Overjet
3.2 ± 0.4
-2.5
-3
+2
Overbite
3.2 ± 0.7
-3
-3
+2
Upper Lip thickness
12.6 ± 1.8
11
11
11
Lower lip Thickness
13.6 ± 1.4
11
11
11
Pog – Pog’
11.8 ± 1.5
7
7
6
Me – Me’
7.4 ± 1.6
3
4
3.5
Nasolabial Angle
103.5 ± 6.8
96
100
100
Upper lip Angle
12.1 ± 5.1
22
17
17
Nasion’- Menton’
124.6 ±4.7
121
125
125
Upper lip length
21.0 ± 1.9
18.5
21
21
Interlabial gap
3.3 ± 1.3
2.5
1
1
Lower lip length
46.9 ± 2.3
49
50
50
Lower 1/3 of face
71.1 ± 3.5
69
72
72
Overbite
3.2 ± 0.7
-3
-3
+2
Mx1 exposure
4.7 ± 1.6
4
4.5
4.5
Maxillary Height
25.7 ± 2.1
22.5
25.5
25.5
Mandibular Height
48.6 ± 2.4
45
46
46
Glabella
-8.5 ± 2.4
-5
-5
-4
Nasal projection
16.0 ± 1.4
12
13
13
Subnasale
0
0
0
0
Upper lip anterior
3.7 ± 1.2
5
5.5
5
Mx1
-9.2 ± 2.2
-4
-6
-6
Md1
-12.4 ± 2.2
-1
-3
-8
Lower lip anterior
1.9 ± 1.4
9
9
3.5
B’ Point
-5.3 ± 1.5
3
3
-3
Pog’
-2.6 ± 1.9
+2
+1
-1.5
A’ Point
-0.1+1.0
0
-1
-1
Soft Tissue Structure
Facial Length
Projection to TVL
37
Table 2-a: CEPHALOMETRIC SUMMARY FOR TWIN-2
CEPHALOMETRICS FOR ORTHOGNATHIC SURGERY COGS- HARD TISSUE ANALYSIS
MEASUREMENTS &
LANDMARKS
CAUCASIAN
NORMS FOR
VALUES
PRETREATMENT
VALUES
PRESURGICAL
VALUES
POSTTREATMENT
VALUES
Cranial Base
Ar-Ptm (|| to HP)
37.1±2.8
29.5
30
30
Ptm-N (|| to HP)
52.8 ±4.1
48.5
48.5
48.5
N-A-Pg(Angle)
3.9O± 6.4
-12 O
-11 O
-2 O
N-A (|| to HP)
0.0 ±3.7
0
0
0
N-B (|| to HP)
-5.3 ±6.7
+9
+6.5
-0.5
N-Pg (|| to HP)
-4.3 ±8.5
+10.5
+8
+2.5
N-ANS ( | HP)
54.7 ±3.2
44.5
45.5
45.5
ANS-Gn ( | HP)
68.6 ±3.8
67
69
67.5
PNS-N ( | HP)
53.9 ±1.7
51
51
51
Horizontal (skeletal)
Vertical (skeletal + dental)
O
O
25
O
26
O
24.5 O
MP-HP (Angle)
23 ±5.9
1 –NF ( | NF)
30.5 ±2.1
27
29
29
1-MP ( | MP)
45 ±2.1
39
38.5
38
6-NF ( | MP)
26.2 ±2.0
23.5
24
24
6-MP ( | MP)
35.8 ±2.6
28
30
28.5
PNS-ANS (|| to HP)
57.7 ±2.5
51
51
51
Ar-Go (linear)
52.0 ±4.2
46
46
46
Go-Pg (linear)
83.7 ±4.6
79
79.5
77
B-Pg (|| to MP)
8.9 ±1.7
7
7
7
Maxilla, Mandible
Ar-Go-Gn (Angle)
O
119.1 ±6.5
133
O
135
O
130.5 O
Dental
OP Upper-HP (Angle)
6.2 O ±5.1
2O
A-B (|| to OP)
-1.1 ±2.0
-9
1 –NF (Angle)
O
111 ±4.7
130
1-MP (Angle)
95.9O±5.2
90 O
38
4O
4O
-8
O
122
-3
O
94 O
122 O
94 O
Table 2-b: CEPHALOMETRIC SUMMARY FOR TWIN-2
ARNETT SOFT TISSUE CEPHALOMETRIC ANALYSIS (STCA)
PARAMETER
CAUCASIAN
NORM FOR
FEMALES
PRETREATMENT
VALUE
PRESURGICAL
VALUE
POSTTREATMENT
VALUE
Dentoalveolar Factors
Maxillary occlusal plane to TVL
95.6 ± 1.8
91
92
92
Mx1 to Mx occlusal plane
56.8 ± 2.5
44.5
49
49
Md1 to Md occlusal plane
64.3 ± 3.2
67
66
64
Overjet
3.2 ± 0.4
-2
-2
+2
Overbite
3.2 ± 0.7
-1.5
-1
+1
Upper Lip thickness
12.6 ± 1.8
10.5
10.5
11
Lower lip Thickness
13.6 ± 1.4
10
9.5
11.5
Pog – Pog’
11.8 ± 1.5
7
7
7
Me – Me’
7.4 ± 1.6
4
4
4
Nasolabial Angle
103.5 ± 6.8
90
94
95
Upper lip Angle
12.1 ± 5.1
23.5
20
20
Nasion’- Menton’
124.6 ± 4.7
117.5
121
121
Upper lip length
21.0 ± 1.9
19
20.5
22
Interlabial gap
3.3 ± 1.3
1.5
0
5.5
Lower lip length
46.9 ± 2.3
47
50
43
Lower 1/3 of face
71.1 ± 3.5
67.5
70.5
70.5
Overbite
3.2 ± 0.7
-1.5
-1
+1
Mx1 exposure
4.7 ± 1.6
3
4.5
3
Maxillary Height
25.7 ± 2.1
22
25
25
Mandibular Height
48.6 ± 2.4
44
45
44
Glabella
-8.5 ± 2.4
-5
-5
-4
Nasal projection
16.0 ± 1.4
12.5
13
12.5
Subnasale
0
0
0
0
Upper lip anterior
3.7 ± 1.2
+6.5
+6
+6
Mx1
-9.2 ± 2.2
-2
-1.5
-4
Md1
-12.4 ± 2.2
0
+1
-5
Lower lip anterior
1.9 ± 1.4
10
10
5.5
B’ Point
-5.3 ± 1.5
+5
+5.5
-3
Pog’
-2.6 ± 1.9
+3.5
+3.5
-3
A’ Point
-0.1+1.0
0
+1
-0.5
Soft Tissue Structure
Facial Length
Projection to TVL
39
MAXILLARY PROTRACTION THERAPY
Authors :
Arunachalam Sivakumar, MDS, MOrth RCSEd
Reader, Dept of Orthodontics
Ashima Valiathan, BDS (Pb), DDS, MS (USA)
Professor and Head
Director of PG Studies, Dept of Orthodontics
Manipal College of Dental Sciences, Manipal
Adjunct Professor of Orthodontics
Case Western Reserve University, Ohio, Cleveland, USA
Address for Correspondence:
Prof. Ashima Valiathan BDS (Pb), DDS, MS (USA),
Professor and Head, Dept of Orthodontics,
Manipal College of Dental Sciences, Manipal, Manipal- 576104
Abstract
The incidence of skeletal Class III malocclusion is rather small in the population, but it is one of
the most difficult malocclusions to treat. Class III malocclusions are often seen with maxillary
retrognathia, mandibular prognathia, or a combination of both. Thus, maxillary protraction is an
emerging paradigm in the early management of skeletal Class III malocclusion. Many investigators have reported on the results of maxillary retrognathic patients treated with face masks. The
majority of these studies noted a counterclockwise rotation of the maxilla with the protraction
headgear treatment. Although this rotation was a benefit in the treatment of low-angle, deep-bite
Class III patients, it is not indicated in Class III cases with high-angle skeletal patterns and anterior
open bites. In order to eliminate these unwanted side effects, some investigators have applied the
protraction force at an angle of 30° downward from the occlusal plane. This article attempts to
consolidate and organize the facts related to the maxillary protraction therapy.
Key Words
Class III malocclusion, Maxillary protraction, face mask, reverse pull headgear.
Ellis and McNamara2 found that 65-67% of all Class III
malocclusions were characterized by maxillary
retrognathism. Sheridan established a valid orthopedic
movement of the maxillary bone in the correction of
maxillary retrusion in Class III malocclusion. He also
stated that orthopedic effects could be achieved
because of the suture morphology and physiology of
the maxilla’s nine articulators when heavy orthopedic
force was employed.3 The use of the protraction face
mask provided a directed constant anterior force to the
maxilla. With the application of constant protraction
forces, there was a significant anterior displacement of
the maxillary structures, accompanied by histologic
changes in the circum-maxillary sutures.4,5,6 An animal
study with tantalum implants and oxytetracycline dyes
showed that heavy intermittent maxillary protraction
force was found to produce forward displacement of
the midface, anterior relocation of the inferior border
of orbit, and gross osseous alterations extending
superiorly to the areas of fronto-maxillary sutures. The
Introduction
In orthopedic treatment an attempt is being made to
influence the morphology of the craniofacial skeleton.
According to Wolff’s law, “the structure and shape of
a bone becomes progressively adapted to all the
changing mechanical forces exerted on the bone; as a
whole bone represents function and responds to stress
placed on it”.1 The sutures in the craniofacial skeleton
are remodeled as secondary growth centers following
application of non-physiologic external forces as well
as with natural growth of the functional matrix. These
fibrous joints are readily remodeled because of their
rich vascularisation. When extra oral force is applied,
the following events occur in sequence;
1. an opening of the suture
2. stretching of sutural connective tissue
3. new bone deposition along the stretched fibres.
4. homeostasis which maintain the sutural width.
40
study also found that post treatment skeletal rebound
was minimal and observed only during the first month
after discontinuation of mechanical forces.7 According
to John Hickham,8 efficient protraction accomplished
any of four movements;
“Maxillary Protractor” which took anchorage from fore
head, temporal and occipital regions. These authors
claimed that if the force is not applied to mandible any
potential TMJ dysfunction is prevented.22 Ngan et al
evaluated the treatment and post treatment effects of a
protraction face mask with an adjustable anterior wire
and hooks to accommodate down ward and forward
pull of maxilla with elastics.23 Toros Alcan et al in 2000
developed a Maxillary Modified Protraction Headgear
(MMPH) to avoid upward and forward rotation while
protracting the maxilla.24
1. close spaces by moving posterior teeth forward.
2. protract a deficient maxilla in Class III cases.
3. rotate arch segments in cleft palate patients.
4. remove hyper anterior contact in TMJ internal
derangement cases
Diagnosis of maxillary insufficiency: clues
Clinical studies by Friede9 and, Rugh and Tindlund10
had been performed in cleft palate patients with Class
III malocclusions due to deficient maxilla. Since then
many studies had been reported on the use of reverse
pull headgear in craniofacial abnormalities.8, 11
Cephalometric values are often unreliable in a young
child, where neither jaw may be identified as the
obvious contribution to a Class III condition. Because
of the variability of the cephalometric analysis, other
factors must also be considered when planning
treatment for the Class III patient. It would be more
appropriate to base treatment decisions on the patients’
facial profile, since an important objective of treatment
is to optimize facial esthetics. One of the reasons that
clinicians are reluctant to render early orthopaedic
treatment for Class III patients is the inability to predict
mandibular growth. Ngan25 proposed the use of serial
Cephalometric radiography and a growth treatment
response vector (GTRV) analysis to predict the excessive
mandibular growth. The GTRV ratio can be calculated
from the following formula:
Historical Development
The concept of protraction in cleft lip and palate
patients was mentioned in German literature in 1875
by Potpeschnigg.12 He attempted forward movement
of the upper first molars by means of a “tooth regulating
machine”. Johnson in 1943 made a headgear anchored
at the head to move the posterior teeth mesially.13 In
1944, Oppenheim commented on the treatment of
mandibular protrusion. He said that, in Class III cases,
diminution of the mandibular movement in a distal
direction by orthodontic means was impossible but it
was possible to counterbalance the protrusion of chin
by bringing the maxilla forward.14 Marx in 1961, pulled
the maxillary arch forward with a cervicomental
apparatus.15 Nelson in 1968 presented a device called
the “anterior pull extra oral appliance” which consisted
of a football type of helmet with a projecting mouth
guard and a heavy resilient lining.16 John Hickham in
1960’s developed “Protraction Headgear” which used
chin and top of the head for support.17 Sheridan in 1968
described the use of oral orthopedics, stating that the
most effective device for moving the maxilla forward
was the “Hickham Chin Cap” and that the treatment of
Class III could be accomplished before maxillary sutural
ossification occurred.3 Dellinger in 1973 used a
modified Hickham Chin Cap in conjunction with a
expansion appliance.18 It was Jean Delaire of Nantes,
who popularized in 1970’s, the concept of maxillary
protraction with his device called facial mask.19 In
1983, Henry Petit modified the Delaire mask by
increasing the amount of force generated by the
appliance.20 Nanda introduced a modified protraction
headgear face bow that aimed to control the point of
force application and direction of the force.21 In 1997,
Conte et al developed a new appliance called
GTRV =
horizontal growth changes of maxilla
horizontal growth changes of mandible
Normally, the mandible outgrows the maxilla each year
by 23% and the GTRV ratio for individuals with Class
I skeletal growth pattern is 0.77. A ratio smaller than
0.77 indicated greater horizontal mandibular growth
and the likelihood that the patient needed surgery.
Clinicians can use the GTRV ratio to determine whether
a Class III malocclusion can be camouflaged
successfully with orthodontic treatment or if surgical
treatment will eventually be necessary.
When to treat
Irie and Nakamura suggested that the period
of Hellman’s dental age IIC to IIIA was the optimal
time.26 Naoto Suda et al observed in the male reverse
pull headgear group, the forward movement of the
maxilla, and increase in the palatal length showing
significant inverse correlation with the bone age, but
not with the chronological age.27 Delaire recommended
that extra oral traction should start early in the primary
dentition stage if possible.19 Cozzani reported that when
41
a child is treated at age 4 years, the direction of growth
of the maxilla coincided with the direction of the
protraction, creating a more stable result.28 Other
investigators had suggested that the most suitable time
for maxillary protraction could be selected based on
the eruption of maxillary teeth29, 30, the developmental
status of circummaxillary suture.31 Most Class III
malocclusions can be detected early, in the mixed
dentition, but fall in the assumptions that the developing
problem was associated with “pseudo” Class IIIs. The
reasons to delay treatment include: fear to treat young
children, lengthening the treatment period, the
possibility of relapse, the hope that the problem will
disappear with growth and the presence of the
permanent anterior teeth. In 1981, Turpin32 developed
some guidelines by which one could decide when to
intercept a Class III malocclusion. He charted some
positive and negative factors. If the patient falls into
the positive line, then early treatment ought to be
considered; but if some of the patient’s characteristics
fall in the negative column, delaying treatment until
condylar growth has ceased may be a better alternative.
appliances deliver the force to the maxilla from the
extra oral appliances, a properly designed appliance is
critical to the effectiveness of the protraction devices.
Campbell used at various times, the lingual arch, fixed
appliances, quad helix, rapid palatal expansion
devices.29 Banded and bonded maxillary splints have,
however, superseded the rest. Patients in whom no
increase in transverse dimension is desired, the
appliance should still be activated for 8-10 days prior
to fitting the headgear in order to disrupt the maxillary
suture system and hence promoted maxillary
protraction. In a sense, palatal expansion
“disarticulates” the maxilla and initiated cellular
response in the suture, allowing a more positive
reaction to protraction forces. It also initiated a
downward and forward movement of the retruded
maxilla. Another advantage of maxillary expansion was
the correction of posterior crossbite that often
accompanied a Class III malocclusion. In addition, a
palatal expansion appliance splinted the maxillary
dentition during protraction and helped to transmit
force from the teeth to the maxilla thus limiting
POSITIVE FACTORS
NEGATIVE FACTORS
Convergent facial type
Divergent facial type
Anteroposterior functional shift
No anteroposterior shift
Symmetrical condylar growth
Asymmetrical growth
Young with growth remaining
Growth completed
Mild skeletal disharmony ANB < - 2
Severe skeletal disharmony ANB > -2
Good cooperation expected
Poor cooperation expected
No familial prognathism
Familial pattern established
Good facial esthetics
Poor facial esthetics
Franchi, Bacetti and McNamara assessed the effects of
protraction therapy in postpubertal subjects with Class
III malocclusion. Orthopedic treatment of Class III
malocclusion was more effective when it was initiated
at an early developmental phase of the dentition (early
mixed or late deciduous) rather than during later stages
with respect to untreated Class III control groups.
Patients treated with rapid maxillary expansion and
facemask therapy in the late mixed dentition, however,
still benefited from the treatment, but to a lesser
degree.33
unwanted tooth movement. Itoh et al34 and Hata et al35
said that there was a possibility of anterior maxillary
constriction when the maxilla was protracted. This was
also counteracted by rapid palatal expansion
appliances. A recent study by Kim et al involving a
meta analysis on 440 articles relating to Class III
malocclusion confirmed that maxillary protraction, in
combination with an initial period of expansion,
provided more significant treatment effects. Although
the results of protraction were similar in both expansion
and non expansion group, the average duration was
much higher in the non-expansion group. Thus the
same degree of improvement was obtained within a
shorter period of time with the expansion appliance. It
can therefore be suggested that the use of an expansion
Intraoral devices
To protract the maxilla effectively, the force should be
applied to the maxilla as a unit. Since the intra oral
42
transformation of the craniofacial complex. Protraction
forces applied parallel to the occlusal plane, at the level
of the maxillary arch, have been shown to produce
anterior rotation (upward) and a forward movement of
the maxilla, whereas protraction forces applied 10 mm
above the Frankfurt horizontal have been shown to
produce posterior rotation (downward) with a forward
movement of the maxilla. In addition, forces applied 5
mm above the palatal plane produced a combination
of parallel forward movement with a downward and
backward rotation of maxilla. 35 Intraoral site of
protraction should be selected by considering the
vertical dimensions of skeletal and dental structures
and the amount of forward displacement of the maxilla
required in the treatment of the individual patients. That
is, if the skeletal discrepancy between both jaws of a
patient is extreme, the anterior traction from the first
molar should be selected; if the tendency of an anterior
open bite is suspected in the patient, more anterior site
of protraction is required. Hickham8, Mermigos41 and
Wisth et al42 applied force at the canine region. Roberts
and Subtelny moved the point of force application distal
to the lateral incisors in order to prevent anterior open
bite while protracting the maxilla.43 Nanda,21 Cozzani,28
Hickham,8 Roberts and Subtelny43 applied forces that
varied between 500–1000g. Some investigators
decreased the appliance wear to 10–14 hrs/day,
however they extended the total treatment duration up
to 1 year. Nanda claimed that 24 hour appliance wear
would achieve more orthopedic effect than 16 hour
appliance wear.21
appliance enhanced the protraction effect in terms of
time with less dental effect.36 Liou described a unique
protocol for an effective maxillary protraction. It
included three components: a new 2-hinged rapid
maxillary expander for a greater amount of anterior
displacement of maxilla, repetitive weekly protocol of
Alternate Rapid Maxillary Expansion and Constriction
(Alt-RAMEC) for disarticulating the maxilla, and
intraoral maxillary protraction springs for noncompliant protraction. On average, the maxilla could
be protracted for 5.8 mm in 3 months and the result
remained stable for at least 2 years later. The rationale
for this technique was sutural expansion/ protraction
osteogenesis.37 Recent randomized controlled trial on
the effects of maxillary protraction therapy with or
without rapid palatal expansion by Vaughn et al
reported no significant differences between expansion
and nonexpansion groups in any measured variable.38
Biomechanical considerations
Considering the biomechanics from a more
comprehensive perspective, one must understand that
any constrained body (i.e. a tooth, a group of teeth, or
an osseous structure joined to other osseous structures
through viable sutures) will react to the forces applied
to it relative to its center of resistance. Stanley Braun
and Harry Legan reported that the location of center of
resistance of the dentomaxillary complex, viewed in
the sagittal plane, to be positioned on a line
perpendicular to the functional occlusal plane (FOP)
located at the distal contacts of the maxillas first molars
as seen on the lateral cephalogram. It is further identified
at one half the distances from FOP to the inferior border
of the orbit.39 An invitro study, using a 3-D finite element
method, found that an anteriorly directed force applied
to the buccal surfaces of the maxillary first molar with
a downward pull from 45-30° to the occlusal plane
gave the most translatory effect.40 Alcan et al, in their
study showed a downward and forward rotation of
maxilla by applying a force of 750g for 17-30 hours /
day at the forehead pad level, which was above the
center of resistance of the maxilla. The direction of force
was forward and parallel to frankfort horizontal.24 Ngan
et al showed that maxillary protraction below the center
of resistance generated an anticlockwise movement.
Protraction elastics attached near the maxillary canines
with downward pull of 30° to occlusal plane minimized
anticlockwise movement.23 Histological modifications
in the zygomaticomaxillary suture vary after maxillary
protraction according to the orientation of the force
system applied. 6 Strain gauges and displacement
transducers have been used on dry human skulls to
show how the location of the applied maxillary
protraction force affects the characteristics and
Treatment effects
The treatment effects of the protraction facemask
therapy were a combination of skeletal and dental
changes of the maxilla and mandible. The maxilla
moved downward and forward with a slight upward
movement in the anterior and downward movement
in the posterior palatal plane as the result of protraction
force; at the same time posterior teeth extruded
somewhat. As a consequence, downward and
backward rotation of the mandible improved the
maxillomandibular skeletal relationship in the sagittal
dimension but resulted in an increased lower facial
height. This rotation was a major contributing factor in
establishing an anterior overjet improvement. A force
exerted by chincup had been speculated to help in
redirecting the mandible downward and backward
growth, upper incisors labial inclination increased,
although lower incisor inclination decreased. It was
postulated that upper incisor proclination was due to
mesial dental movement and lower incisor uprighting
occured as a result of pressure by the chin up and soft
tissue. According to a Meta analysis study by Kim et al,
43
the mean increase in SNA was 1.7°. Labial tipping of
the maxillary incisors range from 0.6°–5.8° (mean 2.8°).
Mandibular incisors tipped lingually, an average of
3.8°.36 Shanker et al showed, that after 6 months of
protraction therapy a mean A-point advancement of
2.4mm compared with 0.2 mm in the control group.
Of this advancement, 75% was found to be due to
skeletal maxillary advancement and 25% was attributed
to local remodeling.44 Baccetti et al with Thinplate
Spline analysis of Class III malocclusion indicated that
the treatment group exhibited a forward displacement
of maxilla associated with a marked advancement of
the point PNS in relation to PTM.45 Clinically, the
maxilla can be advanced 2-4 mm over a 2-15 month
period of headgear treatment.41, 46 Peter Ngan, showed
a significant improvement in dentofacial profile after 6
months of maxillary protraction.47 The skeletal and soft
tissue face profiles were straightened and the posture
of the lips was improved. The normal incisal
relationship (overjet) that was achieved has a significant
impact on the soft tissue overlying both upper and lower
incisors resulting in better lip competence and posture.
The forward movement of maxilla was accompanied
by the corresponding forward movement of soft tissue
profile at 50% to 79% of the hard tissue. In the mandible
the downward and backward movement of the soft
tissue was equivalent to 71% to 81% of corresponding
hard tissue. Ngan indicated a significant reduction in
the severity of Class III relation (reduction in PAR score
at least 30%) with early orthopedic face mask
treatment.48 Alcan et al reported that the angle between
SN and ANS – PNS plane increased by 1.67° indicating
a downward and backward rotation of maxilla.24
Hiyama reported that the superior upper airway
dimension can be altered during maxillary protraction.
Maxillary growth had positive effect on upper airway
dimension.49
need further face mask therapy to keep pace with
excessive mandibular growth.50 Both animal and
human studies have shown that the effects of maxillary
protraction on the maxilla can remain stable for a
period of 1-2 years post treatment. 7 It has been
postulated that the long term effect of treatment might
be related to increased sutural activity at the posterior
part of the maxilla.42 The degree of relapse has been
shown to be negatively correlated with the length of
stabilization.4
Protraction therapy in cleft lip and palate
patients
Patients with cleft lip and palate (CLP) often develop
maxillary retrognathism. This could be due to the
combined effects of the congenital deformity and
surgical repairs. Early protraction of the maxilla with
extra oral forces helps to achieve more balanced
skeletal harmony and favourable occlusion for further
growth to occur. Surgically assisted (incomplete Lefort
I osteotomy without downfracturing maxilla)
orthopedic protraction of maxilla in a group of 14 CLP
patients aged 8-13 years showed a mean maxillary
movement of 7.2mm after 3 weeks of traction followed
by a retention period of 9 weeks for callus formation.51
The advantages of this method are
i)
It allows for early skeletal advancement of the
maxilla with new bone formation in the osteotomy
line.
ii)
There is no need for intermaxillary fixation of
young patients and no need for rigid fixation of
the maxilla by miniplates that can damage teeth
buds and roots at this age.
iii) It can be used in young patients to improve esthetic
appearance an important factor in the
psychological development of adolescents.
Stability after treatment
There are conflicting opinions about the stability of
Class III orthopedic treatment. Delaire19 said that “in
successful cases, the facial skeleton was completely
transformed. The therapeutic action had permitted, and
in fact provoked, the establishment of a normal
equilibrium, without possibility of relapse.” In contrast
Cozzani cautioned that “we cannot consider a Class
III malocclusion fully resolved until facial growth had
ended”.28 Jackson demonstrated that the amount of
relapse after treatment was directly related to the length
of retention.4 Patrick Turly, showed patients with
maxillary deficiency but normal mandibular
dimensions generally showed good stability. Patients
with a significant mandibular component of the
malocclusion required a constant monitoring and may
Tinlund and Rygh reported a more anterior position of
upper jaw and a more posterior position of lower jaw
due to mandible clockwise rotation in a group CLP
patient treated by Bergen CLP team. 52 Also, no
significant difference in maxillary prognathism
achieved after protraction therapy was noted between
Unilateral CLP and Bilateral CLP. Liou and Tsai
described a new protocol for maxillary protraction.
They proposed that through a repetitive weekly protocol
of Alternate Rapid Maxillary Expansions and
Constrictions (Alt-RAMEC), the maxilla in cleft patients
could be protracted more effectively than with a single
course of rapid maxillary expansion (RME).53
44
Other Applications of Face Mask Therapy
Distraction osteogenesis:
i) In closing maxillary spaces, either due to
congenitally missing teeth or extractions, the face
mask can help maintain a forward position of the
anterior dentition while more posterior teeth are
brought mesially to close spaces.
Maxillary advancement using distraction osteogenesis
reportedly has several advantages which includes the
ability to treat skeletal dysplasia at a young age without
having to wait until skeletal maturity. It also treats only
the affected maxilla without having to operate on the
normally positioned or even small mandible. Maxillary
distraction using Rigid. External Distraction (RED)
device allows the clinician to adjust the forces to pass
through (straight advancement) or above (downward
advancement) the center of mass of the maxilla. In this
way the clinician has complete control over the sagittal
rotational movements of the maxilla. Judging from
published reports on cleft patients, the clinical results
of maxillary distraction with RED system appear to be
superior to those obtained with elastic traction and face
mask,56,57 as well as those with internal distractors.58
Figuero and Polley treated successfully 14 CLP patients
with RED technique with significant maxillary
advancement.59
ii) To reduce relapse after maxillary surgical
advancement.
New modalities for maxillary protraction
therapy
1. Implant anchorage
2. Intentional ankylosis
3. Distraction osteogenesis
Implant anchorage:
Integrated devices can serve as an absolute anchor for
moving teeth and the bones of the craniofacial complex.
Endosseous implants require bone availability without
the presence of a vital structure at the implant site. A
study by Smalley et al reported the use of
osseointegrated titanium implants for maxillofacial
protraction in Monkeys.54 The conclusion of the study
were
Conclusions:
1.
The skeletal changes produced by maxillary
protraction varied from 1/3 to 3/4 of total
improvement. The corresponding soft tissue
changes varied from 50% to 80% of hard tissue
change.
2.
1. Titanium implants placed in the facial bones
provided stable anchorage for protraction of the
maxillofacial complex.
Treatment during the early mixed dentition had
been shown to improve the maxillary sagittal
growth.
3.
2. Traction applied directly to the maxilla and/or
zygomatic bones produced marked movement of
the maxillofacial complex anteriorly without
significant changes in the dentoalveolar complex.
The use of rapid maxillary expansion prior to
maxillary protraction for a more pronounced effect
is yet to be resolved. More evidence based answers
warranted.
References
Till date, there are no human studies to validate this
phenomenon. But research is going on extensively in
this field of endosseous implants and onplants to act
as stable anchorage units to effect true skeletal
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47
EVALUATION OF PROXIMAL ALVEOLAR BONE LEVEL CHANGES
DURING ORTHODONTIC TREATMENT
- A COMPARATIVE CLINICAL STUDY
Authors :
Dr. Jatin Ahuja, MDS
Dr. Jatin Ahuja
Reader
Department of Orthodontics & Dentofacial Orthopaedics
Mahatma Gandhi Dental College & Hospital
RIICO Institutional Area
Sitapura, Jaipur - 302022
Rajasthan (INDIA).
Phone: 0141-2770798, 2771001
Dr. J.M. Jeyaraj, MDS
Ex-Professor
Department of Orthodontics & Dentofacial Orthopaedics
A.B.Shetty Memorial Institute of Dental Sciences
Derlakatte, Mangalore, Karnataka.
Dr. U.S. Krishna Nayak, MDS
Dean, Professor & Head
Department of Orthodontics & Dentofacial Orthopaedics
A.B.Shetty Memorial Institute of Dental Sciences
Derlakatte, Mangalore, Karnataka.
Abstract:
The aim of this clinical study was to evaluate the iatrogenic effect of orthodontic treatment on interproximal
crestal alveolar bone and to the compare the changes in cases treated by Preadjusted Edgewise Appliance and
those treated by the Begg Appliance. Two study groups comprising of 10 patients each were treated with either of
the appliances. The radiographic method - Absolute technique as described by Albander et al-was used for
quantification of crestal alveolar bone. Two radiographic examinations were performed, one at the start of treatment
and second at the end of the orthodontic treatment. Each included two intra-oral periapical (IOPA) radiographs of
the maxillary anterior region (right canine to left canine) taken using the paralleling technique. Measurements
were made on the IOPA films and the results evaluated.
Keywords:
Alveolar bone crest, iatrogenic damage, comparison Begg and PEA
Introduction
contradictory. Some authors have reported a
considerable amount of pathological destruction of
crestal bone 2,3,4,5,6,7; others have observed very minimal
changes 1,8,9,10,11, while some authors have found no
effect of orthodontic forces on the proximal alveolar
bone 12,13,14,15. 16.
One of the oft-stated objectives of orthodontic treatment
is to promote better dental health and prolong the life
of the dentition. In practice, however, there are definite
risks in undertaking orthodontic treatment with fixed
appliances such as root resorption, caries and
decalcification, enamel surface marring or enamel
fractures, soft tissue damage, gingival inflammation,
gingival hyperplasia, reduction in the height of alveolar
crest or elimination of the alveolar bone wall1.
This study was undertaken with the following
objectives:
1) To radiographically evaluate the amount of change
in the height of interproximal alveolar bone level
caused by orthodontic tooth movement.
The current information on the effect of orthodontic
forces upon interproximal alveolar bone is
48
b) Maintenance of an edge to edge bite with
approximately 20° anchor bends in the archwire
and Class II elastics delivering forces of
approximately 2 ounces.
2) To compare the changes in cases treated by
Preadjusted Edgewise Appliance and those treated
by the Begg Appliance.
MATERIALS AND METHODS
GROUP B
The study was conducted in the Department of
Orthodontics and Dentofacial Orthopaedics,
A.B. Shetty Memorial Institute of Dental Sciences,
Derlakatte, Mangalore, Karnataka.
This consisted of 10 patients who were treated using
the Preadjusted Edgewise Appliance (Table I) of the
Roth Prescription having 0.022” × 0.028” slot. The
treatment which lasted for a period of 10-12 months
comprised of the following:
CRITERIA FOR PATIENT SELECTION
a) Decrowding using 0.016” diameter preformed
Nitinol wire.
1) All patients had a Class I skeletal base.
2) All patients required the extraction of maxillary first
premolars for correction of crowding, overbite and
proclination of teeth.
b) Leveling of Curve of Spee using 0.016” diameter
reverse curve Nitinol wire.
c) Closure of extraction spaces using the sliding
mechanism with 0.017” × 0.025” stainless steel
archwire in combination with elastic modules and
stainless steel ligature wires (diameter 0.010”)
3) All maxillary teeth were present in all patients with
no history or evidence of trauma.
4) The presence of traumatic bite was ruled out in all
patients.
6) All patients had received oral prophylaxis in the
Department of Periodontics of the same institution,
which included supra-gingival and sub-gingival
scaling as well as education about the oral hygiene
techniques and the importance of maintaining good
oral hygiene especially with the orthodontic
appliance.
Routine home care instructions were given to all
patients. The oral hygiene was analysed every second
appointment (every 6 weeks) with the aid of a disclosing
solution ( Plaksee with erythrosine) and the TureskyGilmore-Glickman modification of the Quigley- Hein
Plaque Index17. A high Index score indicated that the
patient was not adequately maintaining his/her oral
hygiene. Such patients and their parents were given
special instructions and were educated about the
importance of maintaining good oral hygiene.
GROUP A
RADIOGRAPHIC EXAMINATION
This consisted of 10 patients who were treated using
the Begg Appliance (Table I). They had completed the
first two stages of treatment using the appliance which
lasted for 10-12 months.
Two radiographic examinations were performed, one
at the start of treatment and second at the end of the
above mentioned treatment. Each included two intraoral periapical (IOPA) radiographs of the maxillary
anterior region (right canine to left canine) taken using
the paralleling technique. XCP (extension cone
paralleling) instruments were used for positioning the
X-Ray film in the patient's mouth. Radiographs were
taken using a dental x-ray unit (Explor-X) using a long
cone. Dental X-ray film (Kodak) was used and
developed as recommended by the manufacturer.
5) The age and sex of the patients were not
considered.
Stage I comprised of the following:
a) Decrowding using 0.016” diameter preformed
Nitinol wire
b) Bite opening, reduction of overjet and achieving
an edge to edge bite using 0.016” diameter
A.J. Wilcock Special Plus archwire with
approximately 30° anchor bends in combination
with Class II elastics delivering forces of
approximately 2 ounces.
The radiographs were analysed under a magnifier of
x10 magnification for precise location of the landmarks.
The landmarks were marked with a fine marker on the
radiographs. Measurements were made to the nearest
0.1 mm using calipers, directly on the radiographs.
Stage II comprised of the following:
a) Closure of remaining extraction spaces using
0.018” diameter A. J. Wilcock Special Plus archwire
along with Class I elastics delivering forces of
approximately 3 ounces.
To measure the proximal alveolar bone level,
interproximal measurements were made of the distance
between the cementoenamel junction (CEJ) and the
49
alveolar bone crest (AC), along a line parallel to the
long axis of the tooth using the Absolute technique as
described by Albander et al 18 (1985). The CEJ was
defined as the connection between the root surface
and the crown enamel, and the AC as the most coronal
level where the periodontal membrane retained its
normal width 7,8,9.
The values of proximal bone loss of Group A and Group
B were compared and analysed. Statistical analysis of
difference between paired data was performed using
Student's t-test. Differences with probabilities of less
than 5% (p<0. 05) were considered to be statistically
significant.
A widening of the cervical part of the periodontal
membrane was considered to be bone loss only if
accompanied by evidence of oblique resorption. A site
was scored as unreadable if at least one of the reference
points could not be identified.
RESULTS
The proximal distance between CEJ and AC was
measured at 10 sites of each subject, viz. the mesial
surfaces of the right and left maxillary canines, the
mesial and distal surfaces of the two lateral incisors
and the mesial and distal surfaces of the two central
incisors. Hence, altogether 200 sites were measured.
Tables II to VI show the values measured and the
comparisons of the two observation groups.
Altogether, 200 sites were analysed. 12 sites were
excluded because the CEJ or AC could not be identified.
The CEJ-AC distances were measured for the remaining
188 sites.
DISCUSSION
This study was primarily concerned with the ultimate
condition of the interproximal alveolar bone after major
orthodontic treatment using the Begg Appliance and
the Preadjusted Edgewise Appliance. The radiographic
method was used for quantification of crestal alveolar
bone as it is a well accepted technique and has been
proved superior to other clinical methods as it can be
easily standardized 3,5,7,21.
To eliminate magnification errors, the following formula
was used which was based on the one given by Linge
and Linge 19(1991). This formula scaled down both
the radiographs to the same magnification, that of the
first IOPA film.
Proximal bone loss = d2 ( c1 ÷ c2 ) - d1
where d1 represents CEJ-AC distance before treatment
d2 represents CEJ-AC distance after treatment
c1 represents crown length before treatment
c2 represents crown length after treatment
The results showed an increase in CEJ-AC distances
signifying loss of interproximal alveolar bone in both
the study groups (Tables II and III). The values were
statistically very highly significant (p<0. 001) for all sites
in both the groups. This showed that loss of
interproximal alveolar bone does occur regardless of
the technique used. The cause was attributed to the
use of orthodontic forces since all other causes of bone
loss including plaque were eliminated. The result was
in accordance with those of earlier investigations which
indicated loss of interproximal alveolar bone during
orthodontic treatment 2,3,4,5,6,7.
The crown of the central incisor was measured in each
radiograph. To calculate bone loss values of the right
sided teeth, c1 and c2 of the right central incisor were
taken and to calculate bone loss values of left sided
teeth, c1 and c2 of the left central incisor were substituted
in the formula. If the crown of the central incisor was
incomplete in the radiograph, lateral incisor was used
for the same purpose.
In Group A (Begg Appliance) the mean bone loss values
obtained for each site ranged from 0.13 ± 0.05 mm to
0.22 ± 0.07 mm. The minimum value of bone loss
recorded was 0.050 mm while the maximum value
recorded was 0.347 mm (Table II). In Group B
(Preadjusted Edgewise Appliance), the mean bone loss
values obtained for each site ranged from 0.07 ± 0.02
to 0.15 ± 0.08. The minimum value of bone loss
recorded was 0.019 mm while the maximum value
recorded was 0.291 mm (Table III).
The crown length was measured as the distance
between the line joining the mesial and distal incisal
angles and the line joining the mesial and distal CEJ 19.
This method was based on the assumption that the true
dimension of the crown remained constant during the
course of treatment.
All IOPA radiographs have been associated with a
general magnification of the factor 1. 03 according to
Baumrind, Korn and Boyd 20 (1996). Thus, the bone
loss values were then divided by 1. 03 to obtain
absolute values.
This relatively large variability of the results in both
groups matched with those obtained by Hollender,
Ronnerman and Thilander 3(1980), who reported large
intra individual as well as inter individual variations in
Actual Proximal bone loss = [ d2 (c1 ÷ c2 ) - d1 ] ÷ 1. 03
50
loss of crestal alveolar bone. The reason for this
variability could be attributed to the variables not
considered in the study influencing the precise force
delivery system such as
The only comparative study done earlier that comes
close to our study was the one done by Baxter 12 (1967)
when he compared proximal alveolar bone levels in
cases treated by the Edgewise and the Begg appliances.
However, he evaluated the posterior segments and
found statistically non-significant results. Thus, our
study differs from the results of this study.
a) anatomical variables as dimensions of the tooth
and the alveolar bone, the crown to root ratios,
width of the periodontal ligament space and
mechanical properties of the periodontium.
CONCLUSION
b) point of force application in relation to the center
of resistance.
The results indicated the following:
a) Loss of proximal alveolar bone did occur during
orthodontic treatment but the teeth maintained
adequate bone support after orthodontic therapy.
c) ultimately the moment-to-force ratio which is very
difficult to standardise.
In Group A, the mean bone loss for the mesial sites
was 0.155 ± 0.027 mm which was lesser than the mean
bone loss value for the distal sites which was
0.197 ± 0.026 mm. The difference was statistically
significant. Similar trends were observed in Group B
where the mean bone loss value for the mesial sites
was 0.093 ± 0.015 mm as compared to 0.125 ± 0.019
mm for the distal sites. The difference was statistically
highly significant. (Table V).
b) There was a relatively large variability of bone loss
results obtained in both the study groups.
c) There was significantly more loss of proximal bone
on the distal sides of the tooth as compared to the
mesial sides.
d) The Begg appliance caused a significantly higher
loss of proximal alveolar bone as compared to the
Preadjusted Edgewise Appliance.
These results matched with those obtained by Sjolien
and Zachrisson 6 (1973) who reported a greater bone
support on the mesial side than the distal side of the
teeth. The cause of the difference was attributed to the
distal movement of the teeth during orthodontic
movement.
It was concluded from the study that Preadjusted
Edgewise Appliance caused a more “physiological”
tooth movement as compared to the Begg appliance
even though significant bone loss did occur in both
using the current force levels. The use of lighter forces
and further modifications in mechanics may be able to
reduce further this iatrogenic damage to crestal alveolar
bone.
CEJ-AC distance exceeding 2 mm shows significant loss
of bone support 22, 23. In Group A and Group B, there
were no such sites indicating that the teeth maintained
adequate bone support after orthodontic therapy.
REFERENCES:
In Group A, the mean bone loss value was 0.172 ±
0.033 mm as compared to 0.106 ± 0.22 mm of
Group B (Table VI). These values corresponded with
those obtained by Ogaard 5 (1988) who reported who
reported a mean crestal bone loss of 0. 10 mm in the
upper incisor region.
Group A had a higher mean value of bone loss as
compared to Group B and the difference of the values
was statistically very highly significant ( p> 0.001). This
indicated that Preadjusted Edgewise Appliance causes
a more “physiological” tooth movement leading to
reduced loss of crestal alveolar bone as compared to
that caused by the Begg Appliance.
The results obtained for Group A also indicate that
further crestal bone loss is expected during Stage III of
the treatment when root tipping and torquing will take
place.
51
1)
Zachrisson BU. Iatrogenic damage in orthodontic
treatment. Part I. JCO Interview. JCO 1978;
12:102-113.
2)
Hamp SE, Lundstrom F, Nyman S. Periodontal
conditions in adolescents subjected to multiband
orthodontic treatment with controlled oral
hygiene. EJO 1982; 4:77-86.
3)
Hollender L, Ronnerman A, Thilander B. Root
Resorption, marginal bone support and clinical
crown length of orthodontically treated patients.
EJO 1980; 2:197-205.
4)
Kennedy DB, Joondeph DR, Osterberg SK, Little
RM. The effect of extraction and orthodontic
treatment on dentoalveolar support. AJODO 1983;
84:183-190.
5)
Ogaard B. Marginal bone support and tooth
lengths in 19 year olds following orthodontic
treatment. EJO 1988; 10:180-186.
6)
Sjolien T, Zachrisson BU. Periodontal bone
support and tooth length in orthodontically treated
and untreated persons. AJODO 1973; 28-37.
15) Polson AM, Reed BE. Long term effect of
orthodontic treatment on crestal alveolar bone
levels. J Periodontol 1984; 55:28-34.
7)
Zachrisson BU, Alnaes L. Periodontal condition
in orthodontically treated and untreated
individuals. Part II. Alveolar bone loss:
radiographic findings. Angle Orthod 1974;
44:48-55.
16) Reed BE, Polson AM, Subtelny JD. Long term
periodontal status of teeth moved into extraction
sites. AJODO 1985; 88:203-208.
8)
9)
17) Turesky S, Gilmore ND, Glickman I. Reduced
plaque formation by the choloromethyl analogue
of vitamin C. J Periodontol 1972; 43:221-224.
Bondemark L. Interdental bone changes after
orthodontic treatment : A 5 year longitudinal study.
AJODO 1998; 114:25-31.
18) Albander JM, Abbas DK, Waerhaug M, Gjermo P.
Comparison between standardized periapical and
bitewing radiographs in assessing alveolar bone
loss .Community Dentistry and Oral Epidemiology
1985;13:222-225.
Bondemark L, Kurol J. Proximal alveolar bone level
after orthodontic treatment with magnets,
superelastic coils and straight wire appliances.
Angle Orthod 1997; 67(1):7-14.
19) Linge L, Linge BO. Patient characteristics and
treatment variables associated with apical root
resorption during orthodontic treatment. AJODO
1991; 99:35-43.
10) Harris EF, Baker WC. Loss of root length and crestal
bone height before and during treatment in
adolescent and adult orthodontic patients. AJODO
1990; 98:463-469.
20) Baumrind S, Korn EL, Boyd RL. Apical root
resorption in orthodontically treated adults.
AJODO 1996; 110:311-320.
11) Lupi JE, Handelmann CS, Sadowsky C. Prevalence
and severity of apical root resorption and alveolar
bone loss on orthodontically treated adults.
AJODO 1996; 109:28-37
21) Benn DK. A review of reliability of radiographic
measurements in estimating alveolar bone
changes. J Clin Periodontol 1990; 17:14-21.
12) Baxter DH. Effect of orthodontic treatment on
alveolar bone adjacent to cementoenamel
junction. Angle Orthod 1967; 37:35-47.
22) Jorkjend L, Birkeland JM. Alveolar bone loss in
the permanent first molars of Norwegian school
children receiving systematic dental care.
Community Dentistry and Oral Epidemiology
1976; 4:22-24.
13) Eliasson L, Hugoson A, Kurol J, Siwe H. The effects
of orthodontic treatment on periodontal tissues in
patients with reduced periodontal support.
EJO 1982; 4:1-9.
23) Kallestal C, Matsson L. Criteria for assessment of
interproximal bone loss on bitewing radiographs
in adolescents. J Clin Periodontol 1989;
16:300-304.
14) Kloehn JS, Pfeifer JS. The effect of orthodontic
treatment on the periodontium. Angle Orthod
1974; 44:127-134.
52
TABLE I
MEAN VALUES OF GROUP A AND GROUP B AT THE OBSERVATION PERIOD
1.
Age
2.
Sex ( F:M )
3.
Proclination
1 - NA (Linear)
1 - NA (Angular)
Group A
(Mean)
Group B
(Mean)
16.7 years
17.1 years
7:3
8:2
12.1 mm
33.6º
11.7 mm
31.7º
4.
Overjet
5.2 mm
4.8 mm
5.
Arch Discrepancy
1.1 mm
0.7 mm
6.
Overbite
31.0%
33.5%
# Proclination and arch discrepancy values are of the maxillary anterior segment.
# F:M ratio denotes Female: Male ratio
TABLE II
CHANGES IN DISTANCE (mm) BETWEEN THE CEMENTOENAMEL JUNCTION (CEJ)
AND THE ALVEOLAR BONE CRECT (AC) IN GROUP A
Tooth surface
No of sites
Mean ± SD
Minimum
Maximum
Test of
Significance(t)
Right canine
mesial
9
0.13 ± 0.05
0.059
0.194
7.80
****
Right lateral
incisor distal
10
0.17 ± 0.08
0.042
0.345
6.72
****
Right lateral
incisor mesial
10
0.13 ± 0.09
0.050
0.347
4.57
****
Right central
incisor distal
10
0.22 ± 0.07
0.097
0.291
9.94
****
Right central
incisor mesial
10
0.20 ± 0.09
0.062
0.291
7.03
****
Left central
incisor mesial
9
0.17 ± 0.05
0.097
0.260
10.20
****
Left central
incisor distal
10
0.22 ± 0.06
0.155
0.291
11.60
****
Left lateral
incisor mesial
10
0.15 ± 0.05
0.072
0.194
9.49
****
Left lateral
incisor distal
9
0.18 ± 0.07
0.070
0.291
7.71
****
Left canine
mesial
8
0.15 ± 0.07
0.079
0.267
6.06
****
****
Very Highly Significant
p < 0.001
53
TABLE III
CHANGES IN DISTANCE (mm) BETWEEN THE CEMENTOENAMEL JUNCTION (CEJ)
AND THE ALVEOLAR BONE CRECT (AC) IN GROUP B
Tooth surface
No of sites
Mean ± SD
Minimum
Maximum
Test of
Significance(t)
Right canine
mesial
8
0.09 ± 004
0.047
0.170
7.12
****
Right lateral
incisor distal
10
0.15 ± 0.08
0.019
0.256
5.93
****
Right lateral
incisor mesial
9
0.07 ± 0.02
0.043
0.097
11.07
****
Right central
incisor distal
10
0.13 ± 0.07
0.047
0.266
5.89
****
Right central
incisor mesial
9
0.11 ± 0.07
0.056
0.252
4.97
****
Left central
incisor mesial
9
0.10 ± 0.07
0.065
0.291
4.29
****
Left central
incisor distal
10
0.11 ± 0.04
0.074
0.175
8.70
****
Left lateral
incisor mesial
10
0.10 ± 0.04
0.064
0.194
7.91
****
Left lateral
incisor distal
10
0.11 ± 0.03
0.070
0.162
11.00
****
Left canine
mesial
8
0.09 ± 0.02
0.070
0.097
13.25
****
****
Very Highly Significant
p < 0.001
54
TABLE IV
COMPARISON OF CHANGES IN DISTANCE (mm) BETWEEN THE CEMENTOENAMEL
JUNCTION (CEJ) AND THE ALVEOLAR BONE CRECT (AC) IN GROUP A AND GROUP B
Tooth surface
Group A
Mean ± SD
Group A
Mean ± SD
Test of
Significance(t)
Right canine
mesial
0.13 ± 0.05
0.09 ± 0.04
1.98
*
Right lateral
incisor distal
0.17 ± 0.08
0.15 ± 0.08
0.56
*
Right lateral
incisor mesial
0.13 ± 0.09
0.07 ± 0.02
2.06
**
Right central
incisor distal
0.22 ± 0.07
0.13 ± 0.07
3.13
***
Right central
incisor mesial
0.20 ± 0.09
0.11 ± 0.07
3.46
****
Left central
incisor mesial
0.17 ± 0.05
0.10 ± 0.07
2.57
**
Left central
incisor distal
0.22 ± 0.06
0.11 ± 0.04
4.46
****
Left lateral
incisor mesial
0.15 ± 0.05
0.10 ± 0.04
2.47
**
Left lateral
incisor distal
0.18 ± 0.07
0.11 ± 0.03
2.76
**
Left canine
mesial
0.15 ± 0.07
0.09 ± 0.02
2.61
**
*
Not Significant
p > 0.05
**
Significant
p < 0.05
***
Highly Significant
p < 0.01
****
Very Highly Significant
p < 0.001
55
TABLE V
COMPARISON OF MEAN PROXIMAL BONE LOSS VALUES OF MESIAL
AND DISTAL TOOTH SURFACES IN GROUP A AND GROUP B
Tooth surface
Mean ± SD
Test of
Significance(t)
Mesial
0.155 ± 0.027
2.51
Distal
0.197 ± 0.026
**
Mesial
0.093 ± 0.015
2.97
Distal
0.125 ± 0.019
***
Group A
Group B
TABLE VI
COMPARISON OF MEAN PROXIMAL BONE LOSS VALUES (GROUP MEAN VALUES)
OF GROUP A AND GROUP B
Mean ± SD
Group A
Test of Significance(t)
0.172 ± 0.033
Group B
5.26
****
0.162 ± 0.022
*
Not Significant
p > 0.05
**
Significant
p < 0.05
***
Highly Significant
****
Very Highly Significant
p < 0.01
p < 0.001
56
GUIDELINES FOR CONTRIBUTORS
For example : Vashi NS, Begg- Ribbon Arch Combination
Systems (BRACS) - A new approach, J Ind Orthod Soc.
1991;22:30-32.
General: The Journal of Indian Orthodontic Society will
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57
43rd IOS CONFERENCE
The organizing committee of the 43 IOC, with an intent
to match up with the great track record set by earlier
Mumbai IOC’s, started planning and visualizing the
meeting 3 years ahead of the scheduled time of 43
IOC. The main focus of the meeting was quality
scientific contents with added bonus of trade,
l
ura
aug t h e
n
i
in
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at t l i v e s
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entertainment and extramural activities of the members.
All the planning and logistics were on full go when
tragedy struck from unexpected quarters, in the form
of a wanton ‘terror attack’ to disturb the very fabric of
the city. We as the organizers of 43 IOC were left that
uneasy feeling of uncertainty- whether the conference
would see the light of the day or would it be tamely
cancelled! After 6o hours – when the action was onthe never say die spirit of Mumbai, classically
personified by the committee unanimously decided that
the ‘show must go on’ and to go ahead with the conduct
the
tes y a l
a
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Go
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ina B . K .
t
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rof. h a n
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trad ferenc e 43rd
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Th con es th
pre gurat
u
ina
of 43rd IOC, albeit with some curtailment of fun and
frolic taking into consideration, the prevailing mourning
and somber mood.
Our objectives were to communicate effectively and
assure that all is well and there is no need to fear to be
here with us. Our efforts were focused on three fronts
– all the registered members, foreign visitors, trade
fraternity and lastly and most importantly our invited
and guest faculty. We kept our lines of communications
open with frequent updates, to assuage the fear of
unknown and unforeseen insecurities. In addition we
did touch a defiant cord in all concerned, to defy and
he
at t
show solidarity to be with us and send a fitting answer
s
ard
aw n ...
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i
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io
d th tat
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IOC after t
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,
Priz d IOC
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3
4
to these cowards that they cannot deter our freedom!
Our task did seem to have the expected effects, and as
the cliché goes the ‘rest was history’.
Eleven hundred and fifty delegates turned up-with
almost negligible ‘no shows’, all the trade fraternity took
58
L
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59
their appointed place. Out of the 22 invited faculty 20
showed up from all parts of the world, all the pre and
post congress courses ran to its full capacity (Both Dr
Profitt’s and Dr Zachrisson’s courses had more than
210 participants – highest ever by any course on our
soil). All the orations had more than 1000 people in
attendance and scientific contents of the sessions lived
up to our theme ‘Raising the Bar’
The trade partners rose to the occasion. The well
ith
's w t t h e
i
n
a
he
ccu
Co S h a h ile t
The T e j a l e, wh h e
t
g
D r . Loun n j o y .
e
VIP dren artist
l
chi cature
i
car
appointed and air conditioned trade enclosures were
busy, bustling and lively with about 65 stalls doing
brisk business. The mood at the shopping area was
busy but at same time relaxed and informal with
as a
it h ains!!! ion
f
f
o
t
r
Sta
r Tr
f. P
Pro ion fo i CST ayak.
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M
r. A
At
hD
t
i
w
lounging areas, coffee counters and internet kiosks
giving it an international trade show look. Axis lounge
was also used by all delegates to rest in comfort after a
tiring day at the meeting.
‘Beyond Orthodontics’ was a section that encouraged
the other talents of our members like photography,
paintings, posters etc. It did attract a fair participation
and the works were professionally mounted and
displayed at the famous ‘Round Gallery’ of the Nehru
!
fe!! e
s sa ear th
i
i
a
mb it'sn l.
Mu Proff l Hote
T h e Maha
Taj
Centre. This show not only elicited visitors from our
fraternity but also from general public who spent time
watching the works of our orthodontic maestros’!
e
t th
na
o
s
hris
Zac llar!!!
.
r
D e ce
win
The flip side of the meeting was the unfortunate
cancellation of all the entertainment and the Banquet,
which did leave some of the members unhappy. We
were constrained to do this considering the mood and
mourning prevailing in the city then. We are finding
ways and means to make it up to our delegates, god
willing we will…..
Thanking you all earnestly for your role in the successes
cks
che
n
o
t
riss
ach nstree s”...
Z
.
Dr India nding
out ire Be
“W
of 43 IOC,
Dr. MANI K. PRAKASH
Chairman, 43rd IOC
60
but
Clu ing b
”
.
h
K
yt
“A. g an
The ussin ’s!!!
6
c
dis o r 5
s
’
47