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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 communications herein are those of the authors and not 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. FORM OF DECLARATION (See Rule 3) I, Dr. LODD. MAHENDRA declare that I am the Publisher of the newspaper entitled THE JOURNAL OF INDIAN ORTHODONTIC SOCIETY to be printed at Nagaraj and Company Private Limited, 156, Developed Industrial Estate, Perungudi, Chennai - 600 096, and published at No. 48, 4th Street, Padmanaban Nagar, Adyar, Chennai - 600 020, and that particulars in respect on the said newspaper given here under are true the best of my knowledge and belief. 1. Title of the Newspaper : THE JOURNAL OF INDIAN ORTHODONTIC SOCIETY 2. Language(s) in which it is (to be) Published : ENGLISH 3. 4. 5. Periodically of its publication (a) Whether a daily, tri-weekly, bi-weekly, Weekly, fortnightly or otherwise (b) In the case of daily, Please state whether it is morning or evening Newspaper (c) In the case of newspaper other than a daily, Please state the day(s), date(s) on which it is to be published. Retail selling price of the Newspaper Per copy (a) If the newspaper is for free distribution Please state that it is for free distribution (b) If it has only an annual subscription and no Retail price, please state the annual Subscription. Publisher’s Name Nationality Address : Quarterly : Quarterly : : NOT APPLICABLE January, April, July and October Every year : Rs. 5/- (Rupees Five only) : NOT APPLICABLE : : : : NOT APPLICABLE Dr. LODD. MAHENDRA Indian No. 48, 4th Street, Padmanaban Nagar Adyar, Chennai - 600 020 No. 48, 4th Street, Padmanaban Nagar Adyar, Chennai - 600 020 6. Place of Publication (Please give the complete Postal address) : 7. Printer’s Name Nationality Address : : : 8. Name(s) of the printing press(es), where printing is to be conducted and the true and precise description of the premise on which the press(es) is / are installed : 34 M.S. RAJU SESHADRINATHAN Indian Nagaraj and Company Private Limited No. 156, Developed Plots Industrial Estate, Perungudi, Chennai - 600 096 Nagaraj and Company Private Limited No. 156, Developed Plots Industrial Estate, Perungudi, Chennai - 600 096 & LANDMARKS 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 movement. 1. Frost HM. A 2003 update of bone physiology and Wolff’s Law for clinicians. Angle Orthod. 2004 Feb;74(1):3-15. 2. Ellis E, McNamara JA Jr. Components of adult Class III open-bite malocclusion. Am J Orthod. 1984 Oct;86(4):277-90. Intentional ankylosis: 3. Sheridan JJ. Oral orthopedics. J La Dent Assoc. 1968 Summer;26(1):5-8. 4. Jackson GW, Kokich VG, Shapiro PA. Experimental and postexperimental response to anteriorly directed extraoral force in young Macaca nemestrina. Am J Orthod. 1979;75(3):318-33. 5. Kambara T. Dentofacial changes produced by extraoral forward force in the Macaca irus. Am J Orthod. 1977;71(3):249-77. The prime goal of maxillary protraction is to achieve skeletal movement of maxilla without dentoalveolar movement. So it’s necessary to enhance anchorage of maxillary dentition or to reduce resistance of maxilla to protraction. In 1985, Kokich et al reported a case in which intentionally ankylosed maxillary deciduous canines were used as anchorage for protraction.55 45 6. 7. 8. 9. Nanda R, Hickory W. Zygomaticomaxillary suture adaptations incident to anteriorly-directed forces in rhesus monkeys. Angle Orthod 1984;54: 199-210 22. Conte A, Carano A, Sicilianils. A new maxillary protractor. J Clin Orthod 1997;31:523-30. 23. Ngan PW, Hagg U, Yiu C, Wei SH. Treatment response and long-term dentofacial adaptations to maxillary expansion and protraction. Semin Orthod. 1997 Dec;3(4):255-64. Cederquist R. Degree of stability following experimental alteration of midfacial growth with heavy intermittent force. Proc Inst Med Chic 1978;32: 50-1. 24. Alcan T, Keles A, Erverdi N. The effects of a modified protraction headgear on maxilla. Am J Orthod Dentofacial Orthop 2000;117:27-38. Hickham JH. Maxillary protraction therapy: diagnosis and treatment. J Clin Orthod. 1991;25(2):102-13. 25. Ngan P, Wei SH. Early treatment of Class III patients to improve facial esthetics and predict future growth. Hong Kong Dent J 2004;1: 24-30. Friede H, Lennartsson B. Forward traction of the maxilla in cleft lip and palate patients. Eur J Orthod 1981;3:21-39. 26. Irie M, Nakamura S. Orthopedic approach to severe skeletal Class III malocclusion. Am J Orthod. 1975;67(4):377-92. 10. Rygh P, Tindlund R. Orthopedic expansion and protraction of the maxilla in cleft palate patientsa new treatment rationale. Cleft Palate J 1982;19:104-12. 27. Suda N, Ishii-Suzuki M, Hirose K, Hiyama S, Suzuki S, Kuroda T. Effective treatment plan for maxillary protraction: is the bone age useful to determine the treatment plan? Am J Orthod Dentofacial Orthop 2000;118:55-62 11. Meenakshi Iyer, Ashima Valiathan: Class III Skeletal malocclusion. Ind J Orofac Genet 2000; 3(1): 6-11. 28. Cozzani G. Extraoral traction and Class III treatment. Am J Orthod 1981;80:638-50. 12. Potpeschnigg. Deutsche vierteljahrschrift fur zahnheikunde. Monthly Rev Dent Surg 1875;3:464-5. 29. Campbell PM. The dilemma of Class III treatment. Early or late? Angle Orthod. 1983 Jul;53(3): 175-91. 13. Johnson EL. Application of occipital anchorage. Am J Orthod Oral Surg 1943;29:638-47. 14. Oppenheim A. A possibility for physiologic orthodontic movement. Am J Orthod Oral Surg 1944;30:345-68. 30. Tindlund RS. Skeletal response to maxillary protraction in patients with cleft lip and palate before age 10 years. Cleft Palate Craniofac J. 1994 Jul;31(4):295-308. 15. Marx R. Various types of extraoral anchorage devices. Dent Pract 1961;11:203-6. 16. Nelson FO. A new extra-oral orthodontic appliance. Int J Orthod 1968;6:24-7. 31. Melsen B, Melsen F. The post natal development of the palatomaxillary region studied on human autopsy material. Am J Orthod 1982;82:329-42. 17. Hickham JH, Graziano FW. The effectiveness of orthopedic forces in inhibiting mandibular growth. J La Dent Assoc 1970;28:10-12. 32. Turpin DL. Early Class III treatment, unpublished thesis presented at 81st session. Am Assoc Orthod, San Francisco; 1981. 18. Dellinger EL. A preliminary study of anterior maxillary displacement. Am J Orthod 1973;63:509-16. 33. Franchi L, Bacetti T and McNamara JA. Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances. Am J Orthod Dentofacial Orthop. 2004 Nov;126(5):555-68. 19. Delaire J. The crescent maxilla: deductive therapeutics. Trans Eur Orthod Soc 1971:81-102 34. Itoh T, Chaconas SJ, Caputo AA, Matyas J. Photoelastic effects of maxillary protraction on the craniofacial complex. Am J Orthod. 1985;88(2):117-24. 20. Petit H. Adaptation following accelerated facial mask therapy. In: McNamara JA Jr, Ribbens KA, Howe PR, editors. Clinical alteration of the growing face. Monograph 14, craniofacial growth series. Ann Arbor: Center for Human growth and Development, University of Michigan 1983: 253-89. 35. Hata S, Itoh T, Nakagawa M, Kamogashira K, Ichikawa K, Matsumoto M, Chaconas SJ. Biomechanical effects of maxillary protraction on the craniofacial complex. Am J Orthod Dentofacial Orthop 1987; 91:305-11. 21. Nanda R. Biomechanical and clinical considerations of a modified protraction headgear. Am J Orthod. 1980;78(2):125-39. 46 36. Kim JH, Viana MA, Graber TM, Omerza FF, BeGole EA.The effectiveness of protraction face mask therapy: a meta-analysis. Am J Orthod Dentofacial Orthop. 1999;115(6):675-85. 49. Hiyama S, Suda N, Ishii-Suzuki M, Tsuiki S, Ogawa M, Suzuki S, Kuroda T. Effects of maxillary protraction on craniofacial structures and upperairway dimension. Angle Orthod. 2002 ;72(1): 43-7. 37. Liou EJ. Effective maxillary orthopedic protraction for growing Class III patients: a clinical application simulates distraction osteogenesis. Prog Orthod. 2005; 6(2):154-71. 50. Turley PK . Orthopedic correction of Class III malocclusion: retention and phase II therapy. J Clin Orthod. 1996 Jun;30(6):313-24. 38. Vaughn GA, Mason B, Moon HB, Turley PK. The effects of maxillary protraction therapy with or without rapid palatal expansion: a prospective, randomized controlled trial. Am J Orthod Dentofacial Orthop. 2005;128(3):299-309. 51. Rachmiel A, Aizenbud D, Ardekian L, Peled M, Laufer D. Surgically-assisted orthopedic protraction of the maxilla in cleft lip and palate patients. Int J Oral Maxillofac Surg 1999; 28:9-14. 39. Braun S, Lee KG, Legan HL.A reexamination of various extraoral appliances in light of recent research findings. Angle Orthod. 1999;69(1): 81-4. 52. Tindlund RS, Rygh P. Soft-tissue profile changes during widening and protraction of the maxilla in patients with cleft lip and palate compared with normal growth and development. Cleft Palate Craniofac J. 1993;30(5):454-68. 40. Tanne K, Hiraga J, Sakuda M. Effects of directions of maxillary protraction forces on biomechanical changes in craniofacial complex. Eur J Orthod. 1989;11(4):382-91. 53. Liou EJ and Tsai WC. A new protocol for maxillary protraction in cleft patients: repetitive weekly protocol of alternate rapid maxillary expansions and constrictions. Cleft Palate Craniofac J. 2005;42(2):121-7. 41. Mermigos J, Full CA, Andreasen G. Protraction of the maxillofacial complex. Am J Orthod Dentofacial Orthop. 1990;98(1):47-55. 42. Wisth PJ, Tritrapunt A, Rygh P, Boe OE, Norderval K. The effect of maxillary protraction on front occlusion and facial morphology. Acta Odontol Scand. 1987 Jun;45(3):227-37. 54. Smalley WM, Shapiro PA, Hohl TH, Kokich VG, Branemark PI. Osseointegrated titanium implants for maxillofacial protraction in monkeys. Am J Orthod Dentofacial Orthop. 1988;94:285-95. 43. Roberts CA, Subtelny JD. An American board of orthodontics case report. Use of the face mask in the treatment of maxillary skeletal retrusion. Am J Orthod Dentofacial Orthop 1988;93: 388-94. 55. Kokich VG, Shapiro PA, Oswald R, KoskinenMoffett L, Clarren SK. Ankylosed teeth as abutments for maxillary protraction: a case report. Am J Orthod. 1985;88(4):303-7. 44. Shanker S, Ngan P, Wade D, Beck M, Yiu C, Hagg U, Wei SH. Cephalometric A- point changes during and after maxillary protraction and expansion. Am J Orthod Dentofacial Orthop. 1996;110:423-30. 56. Molina F, Ortiz Monasterio F, de la Paz Aguilar M, Barrera J. Maxillary distraction: aesthetic and functional benefits in cleft lip-palate and prognathic patients during mixed dentition. Plast Reconstr Surg 1998;101: 951-63. 45. Baccetti T, Franchi L, McNamara JA Jr. Thin-plate spline analysis of treatment effects of rapid maxillary expansion and face mask therapy in early Class III malocclusions. Eur J Orthod. 1999;21(3):275-81. 57. Krimmel M, Cornelius CP, Roser M. Bacher M, Reinert S. External distraction of the maxilla in patients with craniofacial dysplasia. J Craniofac Surg 2001;12:458-63. 46. Staggers JA, Germane N, Legan HL. Clinical considerations in the use of protraction headgear. J Clin Orthod. 1992;26(2):87-91. 58. Cohen SR, Burstein FD, Stewart MB, Rathburn MA. Maxillary-midface distraction in children with cleft lip and palate: a preliminary report. Plast Reconstr Surg. 1997;99(5):1421-8. 47. Ngan P, Hagg U, Yiu C, Merwin D, Wei SH. Treatment response to maxillary expansion and protraction. Eur J Orthod. 1996;18(2):151-68. 59. Figueroa AA, Polley JW. Management of severe cleft maxillary deficiency with distraction osteogenesis: procedure and results. Am J Orthod Dentofacial Orthop. 1999;115(1):1-12. 48. Ngan P, Yiu C. Evaluation of treatment and posttreatment changes of protraction facemask treatment using the PAR index. Am J Orthod Dentofacial Orthop. 2000;118(4):414-20. 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 publish articles on original research, clinical observations and experiences, reviews, news, comments and letters to the editor. Articles are accepted with the stipulation that they are written in English, are original and have not been submitted for publication elsewhere. Articles will be reviewed by the Editor and Consultants and are subject to editorial revision. All published articles will become the property of the JIOS. 7. Illustrations : All figures (Fig.) must be mentioned sequentially in the text. Each figure must be accompanied by a legend, typed on a separate paper. The illustrations must be of good quality. Good black and white photographs are preferred for black and white reproduction. Coloured photographs will be published at author’s expense where a coloured glossy print is preferred. Cost of coloured printing would be Rs. 500/($ 20) per postcard size photograph in addition to Rs. 600/- ($ 25) towards additional printing charges. Photographs of x-rays should be sent and not the original x-rays. The Editor and Journal Committee reserve the right to reject any article without giving any explanations thereof. The Journal accepts no responsibility for the opinions expressed by the contributors. The Editor/Journal does not guarantee or endorse any products, services advertised in the JIOS. Format : articles should be typewritten on one side of A-4 size (21× 28 c.m.) white paper in double spacing with a sufficient margin. One original and two high quality xerox copies should be submitted. The authors name is to be written only on the first copy but not on two xerox copies which are to be submitted to the Consultants for a critical review. Authors are advised to retain a copy for the reference. Orginal drawings and graphs should be of professional quality. 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Photographs : Authro’s photograph - Passport size, glossy, black and white (3 cm × 4 cm). 1 0. Diagrams: Width preferably 8 cm or 16.5 cm for smaller and wider diagrams respectively. 2. Introduction : The purpose of this para is to answer briefly the question why did you do the study/ clinical procedure/ research? State the objective and OMIT extensive review of literature which is normally found in ‘Thesis’. 11. Letters to the Editor : Are encouraged in order to stimulate a healthy dialogue relating to the specialty. 3. Materials, Methods, Case Histories, Samples : In this section answer only the question what did you do? Give details if the work is original, otherwise, quote only references. 12. Books for Review : Books and monographs will be reviewed, based on their relevance to JIOS readers. Books should be sent to the Editor and will become property of JIOS and will be retained permanently in the Library with the manuscripts. 4. Results and Finding : Give your results only. Use Tables, Charts, Photographs etc. to clarify. 13. Return of Articles : Unaccepted articles will be returned to the authors only if sufficient postage is enclosed with the manuscripts. 5. Discussion : Discuss and point out significance of findings and limitations (What you actually found out), and its clinical implications and comparison with other similar findings. Do not repeat the ‘introduction’. 14. Manuscript should be on a CD Rom also, for easy printing. 6. References : References should be selective and keyed in numerical order to the text - in Vancouver style (NOT alphabetically). Type them double spaced on a separate sheet of paper. Authors are responsible for the accuracy of references. Journal references must include author’s names, article title, abbreviated (as per standards) journal name, year volume number and page number. Book reference must include author’s or editor’s names, chapter title, book title, edition number, publisher, year and page number. 15. Each manuscript should be accompanied by a certificate/ letter stating that it is their original work and not sent for publication anywhere else. For further information write to: The Editor, Journal of Indian Orthodontic Society 48, 4th Street, Padmanabha Nagar, Adyar Chennai - 600 020. India. E-mail : [email protected] 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 he at t l i v e s e r c i n e sile s t t h es o l t u o min w h a 2 those g in f erv y o obs e m o r s . s m ack orie nat n y i n o r A t t g i r o D em Ter c e r mbai Mu 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 r Go ugu ina B . K . t i f f Pro P r o f . rof. h a n P hus p... am d m a b L n dia s , P a l In ourse C. a n IO itio ec trad ferenc e 43rd e 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 ... r i e io d th tat ive resen e c , re he p IOC after t d 2n iles e4 f th .All sm o ai ers inn Mumb w e , Priz d IOC r 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 he at t r. s e ika gat ele arand D ! K ! rs. un! ai s and M b m of. r Mu he ar &P t n k i l o g kin Ang Soa Dr. h wit h unc are a his for C d IO 43r e h t by tics. ked odon n a rth is th ffit n to O o r .P tio f. W ribu Pro cont and he at t h ep oC em OC. N I l of 3rd gha the 4 n i S at ev nje ended a S . tt Mr ll a r - ry we i a F de s ve Tra ir wa e Th e Fa d Tra f. Pro e t th ea c n ie aud the g in eriz sm e nm isso r h Zac f ls o ear p ie's Rab . B f. Pro ... IOC d r 43 tion nta e s pre n. atio c o onv OC B I he at t m do wis n s" i ... llop rever a t "G s fo y a pines a d h p birt ll ha her her a g n hes rati leb es wis e c it m roff S Ti s. P ai.IO r M mb Mu 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. s a pas umb run N 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