Management of Short Face Syndrome with Masseter Muscle Hypertrophy: A Surgery-First Approach.

Short face syndrome (SFS) is a condition with a clinical impression of deficient lower anterior facial height, which is an esthetic disharmony based on vertical facial proportions rather than absolute dimensions. Masseter hypertrophy is one of the etiologic factors in which there is an enlargement of unilateral or bilateral masseter muscles. Clinically, it presents as a quadrangular face characterized by bulging of the mandibular angle giving a muscular appearance. Despite the muscular origin, surgery should be aimed toward bony reduction (osteoplasty) followed by supplemented myotomy. This case report addresses one such case of SFS treated with surgery-first approach and supplemented myotomy with a 1-year follow-up. The esthetic facial profile, pleasant smile and overall good treatment outcome remained stable 1 year after orthognathic surgery and orthodontic treatment.

Efficacy of titratable mandibular advancement device versus continuous positive airway pressure therapy in the treatment of obstructive sleep apnea: A clinical crossover trial.

Background: To compare efficacy of continuous positive airway pressure (CPAP) and oral appliance (OA) in management of various grades of obstructive sleep apnea (OSA). Methods: Thirty polysomnography diagnosed cases of OSA were divided into three groups based on baseline apnea hypopnea index (AHI) as follows: group 1: mild OSA (AHI = 5-14.9), group 2: moderate OSA (AHI = 15-29.9), and group 3: severe OSA (AHI >30) with 10 patients in each group. Half of the patients in each group were randomly allocated to CPAP or OA therapy, and crossover of therapy was performed after two months. AHI, Epworth's Sleepiness Scale (ESS), and mean oxygen saturation (SPO2) were measured at baseline, after each arm of treatment and after the crossover. A questionnaire survey including information regarding pretreatment sleep symptoms and improvement after therapy was performed at above time frames. At the end of therapy, the patients were surveyed regarding satisfaction and perceived effectiveness with both modalities. Results: CPAP was more efficacious in reducing AHI and SPO2 as compared with OA across the three study groups. The improvement in most sleep-related symptoms was higher with CPAP. The satisfaction and perception on effectiveness of treatment were higher with OA than CPAP across three study groups (P-value<0.05 for all). Conclusions: OA is an effective alternative to CPAP across all grades of OSA in selected cases, which is more preferred owing to higher effectiveness and satisfaction among the patients.

Comparison of efficacy between MBT preadjusted edgewise appliance and clear aligner therapy among class I crowding cases: A randomized controlled trial.

Background: To compare the efficacy of McLaughlin Bennett Trevisi (MBT) appliance and Clear Aligner Therapy (CAT) among nonextraction Class I crowding cases. Methods: The study sample (60 patients) was allotted into two equal groups (30 patients each) using block randomization wherein Group 1: treated with 0.018" MBT appliance and Group 2: treated with CAT for correction of malocclusion. At the end of treatment (T1), treatment duration, chairside time, laboratory time, number, and type of appointments were noted from treatment record cards. For comparing the acceptability among patients treated with both modalities at T1, the patients were interviewed regarding the comfort and ease of using an appliance with a questionnaire-based survey. Results: The median number of nonscheduled/emergency and finishing stage appointments was significantly higher in Group 1 compared to Group 2 (P-value <0.001). The median duration of treatment at the scheduled, finishing, and overall appointments, was significantly higher in Group 1 compared to Group 2 (P-value <0.001). The median chairside time of all appointments was significantly higher in Group 1 compared to Group 2 (P-value <0.001). The experience with treatment and overall acceptability was significantly higher in Group 2 compared to Group 1 (P-value <0.001). However, mean laboratory time per aligner fabrication in Group 2 was 30.26 ± 3.45 min against no laboratory time consumed in Group 1. Conclusions: CAT significantly reduces treatment duration, chairside time, number of nonscheduled/emergency, and finishing stage appointments in nonextraction Class I crowding cases. Prospective studies with 3D aligner systems are recommended to add further evidence in this regard. Clinical Trials Registry-India Registration No: CTRI/2018/04/013301.

Correlating Nasal Patency with Obstructive Sleep Apnea in Obese Versus Non-Obese Patients: An Acoustic Rhinometry Study.

The aim of this study was to correlate nasal patency with Obstructive Sleep Apnea (OSA) in obese versus non-obese patients using Acoustic Rhinometry (AR). Eccovision® Acoustic Rhinometer equipment was used to compare nasal cross-sectional areas (CSA1,2 & 3 corresponding to nasal valve region, anterior portion of middle & inferior turbinate and posterior portion of middle & inferior turbinate respectively) and volume in age and gender matched sample divided into three groups: Group 1: Non-obese patients without OSA (25 patients, 13 males and 12 females); Group 2: Non-obese patients with OSA (25 patients, 14 males and 11 females); Group 3: Obese patients with OSA (25 patients, 13 males and 12 females). The mean nasal cross-sectional areas and volume were lower in Group 2 compared to Group 1 but statistically non-significant (P value > 0.05 for all). The mean nasal cross-sectional areas and volume were significantly lower in Group 3 as compared to Groups 1 and 2 (P value < 0.05 for all). BMI showed a statistically significant positive (direct) correlation with AHI in Groups 2 and 3 (P value < 0.05 for both). The nasal cross-sectional areas and volume showed a statistically significant negative (inverse) correlation with AHI in Groups 2 and 3 (P value < 0.05 for both). OSA diagnosed cases with high BMI may not present with an obvious nasal obstruction; the nasal patency may still be compromised due to reduced nasal lumen secondary to obesity. AR, being cost-effective and non-invasive modality; is advocated to evaluate pre-treatment nasal patency, as well as follow up evaluation to ascertain improvement after the intervention.

Effectiveness of Titratable Oral Appliance in Management of Moderate to Severe Obstructive Sleep Apnea-A Prospective Clinical Study with Acoustic Pharyngometry.

To assess effectiveness of titratable Oral Appliance (OA) in management of moderate to severe cases of Obstructive Sleep Apnea (OSA). Thirty Polysomnography (PSG) diagnosed cases of moderate to severe OSA were subjected to a thorough cranio-facial-dental evaluation, a detailed sleep history and three dimensional assessment of upper airway geometry utilising Acoustic Pharyngometry (AP) (Eccovision, sleep group solutions). A titratable OA was delivered to all patients for mandibular advancement. Apnea Hypopnea Index (AHI), Oxygen Saturation (SPO2), Epworth's Sleepiness Scale (ESS), Mean area and volume of upper airway were recorded at Baseline (T0) and after 08 weeks of appliance delivery (T1). The mean AHI & ESS scores were significantly lower and SPO2 was significantly higher at T1 compared to T0 (P-value < 0.05 for all). The mean area and volume of upper airway at T1 were significantly higher compared to values at T0 (P-value < 0.05 for both). The mean area showed 19.51% increase at T1 whereas mean volume increased by 18.55%. OA therapy is highly efficacious in cases with moderate to severe OSA, especially, in those with retrognathic mandible. This modality should be considered as an effective alternate to Continuous Positive Airway Pressure (CPAP) therapy in non-compliant patients rather than no treatment. AP is an effective modality to predict airway changes after advancement with OA, to ascertain follow up changes and is highly recommended in routine clinical practice. Large scale, multicenter studies are recommended to elaborate the findings of the present study and to add better quality evidence in this regard.

Correlation between scientometrics and altmetrics score of scholarly literature of Medical Journal Armed Forces India.

Background: Present article was an attempt to study correlation of scientometrics and altmetrics of scholarly output of Medical Journal Armed Forces India (MJAFI) during the period from 2010 to 2018. Methods: The study was carried out by "DIMENSIONS", Webometric Analyst 4.1, VOSviewer, version 1.6.10, database to identify year-wise number of publications, their accessibility, altmetric attention, field citation ratio, and relative citation ratio of top 100 articles between 2010 and 2018. Pearson correlation test was used to assess data statistically using SPSS software, version 21. Results: The study found that maximum publications were in 2015, i.e. 21.44% followed by 2018, i.e. 11.52% with 1053 articles open access and 318 articles closed access (1371). Total 317 altmetric attention received by total 1371 articles, and "Clinical Sciences" category published most of publications with 0.55 mean field citation ratio (FCR) and 0.31 mean relative citation ratio (RCR). The positive correlation value between citations and altmetric scores obtained was 0.88. It was also observed that the topmost article among the top 100 has a maximum RCR (8.24) and FCR (19.3). Conclusion: Present study found that articles published in MJAFI are getting favorable attention at both academic as well as social platform; however, the constant improvement and rigorous maintenance of standards is utmost important by publishing high-quality evidence-based studies and its subsequent dissemination at both academic and non-academic platform, which might be beneficial to not only medical field but also well-being of entire human race.

Long-Term Study of Relapse After Mandibular Orthognathic Surgery: Advancement Versus Setback.

Background: Relapse is a continuing process and should be evaluated on a long rather than short term. Materials and Methods: Treatment records of 46 patients who underwent mandibular orthognathic surgery were divided into two groups, i.e. Group 1: Mandibular Advancement (MA) surgery (n = 26) and Group 2: Mandibular Setback (MS) surgery (n = 20). Lateral cephalograms were traced at T0 (01 week before surgery), T1 (01 week after surgery), T2 (01 year after surgery) and T3 (minimum 05 years after surgery) to study short- and long-term skeletal and dental relapse in horizontal, vertical and angular parameters selected for the study. Relapse was correlated with gender, age, amount of surgical movement and intra-operative change in mandibular plane angle to study effect of these factors on relapse. Results: All horizontal, vertical and angular parameters studied showed significant relapse at short term (from T1 to T2) which continued significantly till long-term evaluation (T2 to T3) in both groups (P value < 0.001). Horizontal relapse in all parameters, vertical relapse in all parameters (except Pog and overbite at T1-T2) and angular relapse in all parameters (except Ramus inclination at T1-T2) was significantly higher in Group 2 compared to Group 1 (P value < 0.001 for all). Relapse showed significant and positive correlation with amount of surgical movement and intra-operative change in mandibular plane angle in both groups (P value < 0.05 for all). Conclusion: Both MA and MS surgeries show significant relapse on both short- and long-term evaluation which it is higher in MS as compared to MA surgeries.

Development of difficulty index for management of impacted maxillary canine: A CBCT-based study.

BACKGROUND: The aim of this study was to propose an Impacted Canine Treatment Difficulty Index using Cone-beam Computed Tomography (CBCT) imaging to assess difficulty anticipated during the alignment of impacted maxillary canine and further validate the index in clinical set up. METHODS: Pre-treatment CBCT of 15 patients with unilateral or bilateral impacted maxillary canine aged between 12 and 30 years were selected. All the following five factors were assessed on CBCT image: 1) angulation, 2) vertical position, 3) bucco-palatal position, 4) horizontal position and 5) rotation. Two orthodontists evaluated the pre-treatment CBCT for the selected five factors and allocated a total difficulty score. To validate the proposed difficulty index in clinical settings, a team of oral and maxillofacial surgeons were included in the study to grade the difficulty encountered during surgical procedure. RESULTS: The distribution of difficulty score recorded by observer 1 was significantly associated with the difficulty score recorded by observer 2 (P-value < 0.001), with relatively higher level of linearly weighted Cohen's kappa value of 0.610. The distribution of difficulty score recorded by oral and maxillofacial surgeon was significantly associated with the difficulty score recorded by observer 1 (P-value < 0.01), with relatively higher level of linearly weighted Cohen's kappa value of 0.667. The distribution of difficulty score recorded by orthodontist was significantly associated with the difficulty score recorded by observer 1 (P-value < 0.001), with relatively higher linearly weighted Cohen's kappa value of 0.819. CONCLUSION: Impacted Canine Treatment Difficulty Index using CBCT imaging could be used to assess the difficulty that would be anticipated during the alignment of impacted maxillary cuspid.

Comparison of long-term skeletal stability following maxillary advancement using rigid external distraction in growing and non-growing patients with cleft lip and palate: a systematic review and meta-analysis.

OBJECTIVES: To compare the long-term skeletal stability following maxillary advancement using Rigid External Distraction (RED) in growing and non-growing patients with Cleft Lip and Palate (CLP). METHODS: Data sources: A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from database inception till August 2020 in MEDLINE-PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Science Direct, Google Scholar and a manual search in the institutional library. Study eligibility criteria, participants and intervention: All available literature published in English, with a minimum of six human subjects with well-defined age range either 7-14.9 years or 15-30 years, follow up period of a minimum of 12 months assessing the skeletal stability as horizontal change at Point A (Subspinale) following maxillary advancement using a RED device, without the use of rigid internal fixation or bone grafts were included in the study. Study appraisal and synthesis method: The quality assessment of selected articles was done using the Newcastle-Ottawa scale. The meta-analysis was carried out with Q statistic method, I-squared statistics, fixed-effect model to estimate pooled mean and Begg-Mazumdar bias indicator. RESULTS: Selected nine articles that were qualitatively assessed for relapse rate following maxillary advancement using a RED device, showed consistent and stable results. The meta-analysis found no significant difference in long-term skeletal stability of maxillary advancement by RED device in growing and non-growing patients with CLP [(growing group: Pooled proportion = 0.2927; 95% CI = 0.1534 to 0.4319) (non-growing group: Pooled proportion = 0.23077; 95% CI = 0.09854 to 0.36300)]. LIMITATIONS: No study, as revealed by the search, was available that compared the two groups as defined by the inclusion criteria. Data for the two groups were retrieved from different studies and meta-analysed. CONCLUSION: RED is an effective modality for correction of maxillary hypoplasia secondary to CLP, requiring large maxillary advancement. The technique can be used in young and adult patients with similar long-term results. PROSPERO REGISTRATION NUMBER: CRD42020205513.

Effect of Mandibular Setback Surgery on Tongue Length and Height and Its Correlation with Upper Airway Dimensions.

INTRODUCTION: The changes in length and height of tongue following mandibular setback (MS) surgery may affect pharyngeal airway dimensions. There is limited literature correlating tongue dimensional changes with linear and volumetric airway changes following MS with bilateral sagittal split ramus osteotomy (BSSRO) in skeletal class III patients. MATERIALS AND METHODS: Treatment records of 18 patients who underwent MS with BSSRO were evaluated for changes in tongue and linear airway dimensions, mean airway volume and area at T1 (1-week pre-surgery), T2 (6-month post-surgery) and T3 (2-year post-surgery). Amount of MS was recorded from case sheets of patients. Mean tongue length reduced, whereas mean tongue height increased at T2 compared to T1 (P value = 0.001 for both). Linear, area and volumetric airway parameters at T2 were significantly reduced (P value = 0.001). All parameters showed statistically nonsignificant increase from T2 to T3 (P value > 0.05). Correlation analysis showed that change in tongue length at T3 did not show statistically significant correlation with amount of MS, changes in linear, area and volumetric airway parameters (P value > 0.05). However, the change in tongue height at T3 showed a significant (P value < 0.05) negative correlation (r value = - 0.742) with change in posterior airway space (PAS). CONCLUSIONS: The appraisal of tongue length and height after MS surgery should be an integral part of diagnosis and treatment planning. The retro-positioning of tongue and increase in its height after MS surgery may compromise pharyngeal airway especially PAS. Additional options such as bi-jaw surgery, debulking of tongue volume and genioplasty should be explored to minimize adverse effects post-surgically.

Comparison of in vivo and in vitro force decay of elastomeric chains/modules: a systematic review and meta analysis.

BACKGROUND: The study evaluated and compared the force decay of orthodontic elastomeric chains/modules in both in vivo and in vitro settings. METHODS: A protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was formulated and registered with the International Prospective Register of Systematic Reviews. A total of 53 articles (44 in vitro and 9 in vivo studies) found via search of the electronic databases of Cochrane and the National Library of Medicine (MEDLINE; PubMed), and manual search of the gray literature from institutional library resources, were selected. Data extraction, quality analysis, risk of bias assessment, and meta-analysis of the level of force decay of elastomeric chains/modules were conducted per standard protocol, and suitable statistical analyses were applied. RESULTS: The mean force decay in the in vivo setting was 41.9% at 24 hours, 42.6% after 1 week, 46.8% after 2 weeks, and 55.0% after 3 weeks. Similarly, the force decay in the in vitro studies was 38.9% at 24 hours, 42.1% after 1 week, 44.6% after 2 weeks, and 51.1% after 3 weeks. However, at the 95% confidence interval, the force decay rates of in vivo and in vitro studies overlap, with a statistically insignificant difference in force decay observed in the in vivo and in vitro settings. CONCLUSIONS: This systematic review and meta-analysis observed more force decay in the in vivo studies versus the in vitro studies (although this difference was statistically insignificant), with the maximum force decay occurring during the initial days, with a reduction to approximately 50% within 3 weeks. Hence, change of the elastomeric chains/module, at intervals of 3 weeks, is advised. (PROSPERO registration no. CRD42020209535).

Evaluation of Airway Dimensions Following Mandibular Setback with Surgery-First Orthognathic Versus Conventional Orthognathic Approach.

BACKGROUND: To evaluate changes in airway dimensions following mandibular setback with conventional orthognathic approach (COA) and surgery-first orthognathic approach (SFOA). MATERIALS AND METHODS: Treatment records of 20 patients who underwent mandibular setback with SFOA/COA were divided into two groups (COA and SFOA, ten patients in each group). Acoustic pharyngometry values were obtained at T0 (01 week prior to surgery), T1 (01-month post-surgery) and T2 (01-year post-surgery). Percentage change in mean volume and area was obtained at T1 (T1-T0) to evaluate airway changes and at T2 (T2-T1) to compare relapse of airway changes in both groups. Changes in airway per mm setback at T1 (T1-T0) and T2 (T2-T1) were also obtained in both groups. RESULTS: For both parameters, SFOA showed greater reduction at T1 and greater relapse at T2 as compared to COA. The reduction in airway volume at T1 was 0.56 mm/mm setback in COA compared to 1.06 mm/mm setback in SFOA (P-value > 0.05). The relapse in airway volume at T2 was 0.15 mm/mm setback in COA compared to 0.25 mm/mm setback in SFOA (P-value > 0.05). The reduction in area at T1 was 0.062 mm/mm setback in COA compared to 0.110 mm/mm setback in SFOA (P-value > 0.05). The relapse in area at T2 was 0.016 mm/mm setback in COA compared to 0.034/mm setback in SFOA (P-value < 0.05). CONCLUSION: In setback cases, SFOA has greater airway reduction immediate post-surgically and greater relapse at 01-year follow-up. Predicting these changes at diagnostic and treatment planning stage may prevent potential adverse events on airway.

Quantifying Upper Airway Changes Following Mandibular Orthognathic Surgery.

ABSTRACT: The aim of this study was to quantify upper airway changes following mandibular orthognathic surgery. Treatment records of 50 patients who underwent mandibular orthognathic surgery were divided into 2 groups, that is, Group 1: Cases treated with Mandibular Advancement Surgery and Group 2: Cases treated with Mandibular Setback Surgery with 25 patients in each group. The Lateral Cephalogram and Acoustic Pharyngometry records of both groups were studied at T0 (01 week before surgery) and T1 (01 year postsurgery) for changes in linear airway measurements (Nasopharyngeal Airway Space - NAS, Superior Airway Space - SAS, Posterior Airway Space - PAS and Hypopharyngeal Airway Space (HAS)), hyoid bone position (Mandibular Plane Hyoid distance), mean area and mean volume. The percentage change and change in these parameters per millimeter advancement or setback of mandible at T1 was calculated. A significant increase in linear airway parameters (SAS and PAS); decrease in hyoid distance; and increase in volume and area of upper airway was observed at T1 in Group 1 and reverse was observed in Group 2. The change in airway parameters (SAS, PAS, mean volume and area) was more significant in Group 1 as compared to Group 2. In the current airway centric approach, meticulous assessment and prediction of long-term airway changes post surgery should be an integral part of ortho-surgical diagnosis and treatment planning and suitable modifications in the treatment plan must be made to cater for any potential adverse effects on airway.

Does Presurgical Nasoalveolar Molding Have a Long-Term Effect on Nasal and Upper Airway Dimensions?

OBJECTIVES: To compare nasal and upper airway dimensions in patients with cleft lip and palate (CLP) who underwent nasoalveolar molding (NAM) with those without NAM during infancy using acoustic pharyngometry and rhinometry. MATERIALS AND METHODS: Eccovision acoustic pharyngometry and rhinometry (Sleep Group Solutions) was used for assessment of mean area and volume of nasal and upper airway in patients with complete unilateral CLP (age range 16-21 years) treated with NAM (group 1, n = 19) versus without NAM (group 2, n = 22). RESULTS: The mean nasal cross-sectional areas and volume were higher in group 1 compared to group 2 on both cleft (P value <.001) and noncleft side (P value >.05). The mean area and volume of upper airway were also significantly higher in group 1 compared to group 2 (P value <.05). CONCLUSIONS: Nasoalveolar molding being one of the first interventions in chronology of treatment of patients with CLP, its long-term outcome on nasal and upper airway patency needs to be ascertained. The results of the present study show that the patients with CLP who have undergone NAM during infancy have better improvement in nasal and upper airway patency compared with those who had not undergone NAM procedure. The basic advantages of being noninvasive, nonionizing and providing dynamic assessment of nasal and upper airway patency make acoustic pharyngometry and rhinometry a diagnostic tool of choice to be used in patients with CLP.

Evaluation of Nasal Patency Among Patients With Unilateral Cleft Lip and Palate: Cleft Versus Non-Cleft Side.

OBJECTIVE: To evaluate the nasal patency using acoustic rhinometry (AR) in patients with unilateral cleft lip and palate (UCLP) and to ascertain the rhinological importance of the same. METHODS: Eccovision Acoustic Rhinometer system was used for assessment of nasal cross-sectional area (CSA) and volume in 15 patients with UCLP. The CSA1, CSA2, and CSA3, which represent the CSA at the nasal valve area and anterior end of the inferior turbinate, the anterior half of the inferior turbinate and the anterior end of the middle turbinate, and the region of middle portion of middle turbinate, respectively, were compared on the cleft and non-cleft side. RESULTS: The mean ± SD of CSA1, CSA2, and CSA3 as well as the overall nasal CSA were significantly higher on non-cleft side compared to cleft side (P value < .001). The mean ± SD of nasal volume was also significantly higher in non-cleft side compared to cleft side (P value < .001). CONCLUSIONS: The nasal patency among patients with UCLP demonstrates a range of impairments that can be objectively measured using acoustic rhinometry. The orthodontic, orthopedic, or orthosurgical management of maxillary deficiency in these patients can affect the nasal area and volume and can have an impact on breathing, speech, and sleep. The pretreatment assessment may be useful to identify patients who are at potential risk of deterioration of nasal patency and airway post-intervention. Taking into consideration the multiple diagnostic procedures in the course of long-term multidisciplinary treatment of patients with cleft lip and palate, a noninvasive investigation technique such as AR may be the preferred mode of investigation to ascertain nasal patency.

Effect of Mandibular Advancement Surgery on Tongue Length and Height and Its Correlation with Upper Airway Dimensions.

INTRODUCTION: The spatial position and dimensions of oral and pharyngeal soft tissues change post-mandibular advancement (MA) surgery which involves changes in position of soft palate, tongue and associated musculature. There is no study which simultaneously evaluates changes in tongue length and height post-MA surgery and correlates these changes with changes in upper airway dimensions and the amount of MA. MATERIALS AND METHODS: Treatment records of 18 patients that underwent MA with bilateral sagittal split ramus osteotomy were evaluated at T1 (01 week before surgery) and T2 (06 months post-surgery). Linear airway and tongue measurements were done on lateral cephalogram. Mean volume and mean pharyngeal area values were recorded from the acoustic pharyngometry (AP) records of patients. RESULTS: A statistically significant increase in tongue length (P value < 0.001) and nonsignificant change in tongue height were observed at T2 (P value > 0.05). A statistically significant increase in airway parameters recorded on both lateral cephalogram and AP was observed at T2 (P value < 0.001). Correlation analysis did not show a statistically significant correlation of change in tongue length and tongue height at T2 with the amount of MA, change in airway parameters on lateral cephalogram and AP (P value > 0.05). CONCLUSIONS: Mandibular advancement surgery is a viable option for improvement in pharyngeal airway in skeletal Class II patients with retrognathic mandible. Changes in tongue length observed in our study may correspond to the stretch of protruders of tongue, especially genioglossus, and may point toward possible relapse on a long-term follow-up.