Comparative assessment of changes in pharyngeal airway space in cases of obstructive sleep apnoea with a customized mandibular repositioning appliance - a clinical study.

OBJECTIVES: The present study aims at evaluating the effects of a customized mandibular repositioning appliance on the pharyngeal airway, nocturnal sleep patterns, daytime discomfort and occlusal changes in established cases of adult obstructive sleep apnoea. MATERIAL AND METHODS: Ten consecutive patients with a complaint of snoring and disturbed sleep were included in the study. The primary diagnosis was established by the Epworth sleepiness scale, clinical examination, history and subsequently the diagnosis was substantiated through assessment of the pharyngeal airway space on a lateral cephalogram and polysomnography. A customized mandibular repositioning appliance was used to advance the mandible sequentially every 6 months, using 4 sets of the appliance. Pre and post-treatment evaluations were performed to establish, effects and changes in the outcome of obstructive sleep apnoea. RESULTS: The study revealed significant increase in the mean pharyngeal widths of upper airway and velum dimension with antero-superior repositioning of hyoid bone. Epworth sleepiness scale score improved significantly from baseline with clinically evident change in daytime discomforts. Significant decline in the mean apnoea/hypopnea index, oxygen desaturation index, respiratory disturbance index, heart rate, snoring and a significant increase in mean oxygen saturation of arterial blood was observed. No evident change noticed in occlusion except lower incisor inclination. CONCLUSION: The customized mandibular repositioning appliances are effective in the management of adult obstructive sleep apnoea with a significant improvement observed in the airway patency and polysomnography parameters with clinically non-significant effects on dental occlusion..

Orthodontic retention to have and to hold.

Data sourcesCochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, US National Institutes of Health Trials Registry and The World Health Organization (WHO) Clinical Trials Registry Platform, abstracts from the British Orthodontic Conference, the European Orthodontic Conference and the International Association for Dental Research (IADR) from 2011 to 2015 and the bibliographies of identified studies.Study selectionRandomised controlled trials (RCTs) involving children and adults who had had retainers fitted or adjunctive procedures undertaken to prevent relapse following orthodontic treatment with braces were considered.Data extraction and synthesisTwo reviewers independently selected studies, abstracted data and assessed study quality. For continuous data mean differences (MD) with 95% confidence intervals (CI) were calculated with ratios (RR) and 95% CI for dichotomous outcomes.ResultsFifteen studies involving a total of 1722 patients were included. Seven studies were considered to be at high risk of bias, four at low risk and four at unclear risk. For removable retainers versus fixed retainers (three studies) there was low quality evidence that thermoplastic removable retainers provided slightly poorer stability in the lower arch than multistrand fixed retainers: MD (Little's Irregularity Index, 0 mm is stable) 0.6 mm (95% CI 0.17 to 1.03) and of less gingival bleeding with removable retainers: RR 0.53 (95%CI; 0.31 to 0.88). Patients found fixed retainers more acceptable to wear, with a mean difference on a visual analogue scale (VAS; 0 to 100; 100 being very satisfied) of -12.84 (95% CI -7.09 to -18.60).For different types of fixed retainers (four studies) data from three studies (228 patients) comparing polyethylene ribbon bonded retainer versus multistrand retainer were pooled showing no evidence of a difference in failure rates. RR = 1.10 (95%CI; 0.77 to 1.57).Pooled data from two trials (174 patients) comparing the same types of upper fixed retainers, showed a similar finding: RR =1.25 (95%CI; 0.87 to 1.78).For different types of removable retainers (eight studies) one study at low risk of bias comparing upper and lower part-time thermoplastic versus full-time thermoplastic retainers showed no evidence of a difference in relapse (graded moderate quality evidence). Another study, comparing part-time and full-time wear of lower Hawley retainers, found no evidence of any difference in relapse (low quality evidence). Two studies at high risk of bias suggested that stability was better in the lower arch for thermoplastic retainers versus Hawley, and for thermoplastic full-time versus Begg (fulltime) (both low quality evidence). In one study, participants wearing Hawley retainers reported more embarrassment more often than participants wearing thermoplastic retainers: RR 2.42 (95% CI 1.30 to 4.49; one trial, 348 participants, high risk of bias, low quality evidence). They also found Hawley retainers harder to wear. There was conflicting evidence about survival rates of Hawley and thermoplastic retainers.For combination of upper thermoplastic and lower bonded versus upper thermoplastic with lower adjunctive procedures versus positioner (one study) there was no evidence of a difference in relapse between the combination of an upper thermoplastic and lower canine to canine bonded retainer and the combination of an upper thermoplastic retainer and lower interproximal stripping, without a lower retainer. Both these approaches are better than using a positioner as a retainer.ConclusionsWe did not find any evidence that wearing thermoplastic retainers fulltime provides greater stability than wearing them part-time, but this was assessed in only a small number of participants. Overall, there is insufficient high quality evidence to make recommendations on retention procedures for stabilising tooth position after treatment with orthodontic braces. Further high quality RCTs are needed.

Hawley or vacuum-formed retainers following orthodontic treatment?

DATA SOURCES: Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, ISI Web of Science, LILACS. In addition, Pro-Quest Dissertation and Thesis database and Pro-Quest Science Journals. Hand searches were also carried out in American Journal of Orthodontics and Dentofacial Orthopedics, Angle Orthodontist, European Journal of Orthodontics and Journal of Orthodontics. STUDY SELECTION: Two reviewers independently selected studies, and randomised, quasi-randomised (RCTs) and controlled clinical trials (CCTs) were considered. Studies with at least six months follow-up were included. DATA EXTRACTION AND SYNTHESIS: Data extraction and risk of bias assessment were carried out independently by two reviewers. A narrative summary was presented as a meta-analysis could not be performed. RESULTS: Seven studies were included (five RCTs, two CCTs). Three were considered to be at low risk of bias, three at moderate risk and one at high risk. There was some evidence to suggest that no difference exists to distinguish between the HRs and VFRs with respect to changes in intercanine and intermolar widths after orthodontic retention. There was insufficient evidence to support the use of VFRs over HRs in relation to occlusal contacts, cost effectiveness, patient satisfaction and survival time. CONCLUSIONS: This systematic review suggests that further high-quality RCTs regarding the differences between HRs and VFRs during orthodontic retention are necessary to determine which retainer is the better selection for orthodontists.

Early orthodontic treatment reduced incisal trauma in children with class II malocclusions.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase. STUDY SELECTION: Randomised controlled trials (RCTs) of orthodontic treatments (either one- or two-phase) with any type of orthodontic braces (removable, fixed, functional) or head-braces compared with late treatment with any type of orthodontic braces or head-braces; or, on any type of orthodontic braces or head-braces compared with no treatment or another type of orthodontic brace or appliance to correct prominent upper front teeth. DATA EXTRACTION AND SYNTHESIS: Study selection, risk of bias assessment and data extraction were carried out independently by at least two reviewers. The primary measure of effect was over jet measured in millimetres or by any index of malocclusion. Odds ratios (ORs) and 95% confidence intervals (CIs) were used for dichotomous outcomes, mean differences (MDs) and 95% CIs for continuous outcomes and a fixed- effect model for meta-analyses as there were fewer than four studies. RESULTS: Seventeen studies involving 791 patients were included. The overall quality of the evidence was low with only two of the 17 studies being assessed as at low risk of bias. Three trials (n = 343) compared early (two-phase) treatment (7-11 years of age) with a functional appliance with adolescent (one-phase) treatment.Statistically significant differences in over jet, ANB and PAR scores were found in favour of functional appliance when the first phase of early treatment was compared with observation in the children due to receive treatment in adolescence. However, there was no evidence of a difference in the over jet between the groups at the end of treatment. A statistically significant reduction in the incidence of incisal trauma (OR 0.59, 95% CI 0.35 to 0.99, P = 0.04) in favour of two-phase treatment with functional appliance was seen. The incidence of incisal trauma was clinically significant with 29% (54/185) of patients reporting new trauma incidence in the adolescent (one-phase) treatment group compared to only 20% (34/172) of patients receiving early (two-phase) treatment.Two trials (n = 285) compared early (two-phase) treatment using headgear, with adolescent (one-phase) treatment. Statistically significant differences in over jet and ANB were found in favour of headgear when the first phase of early treatment was compared with observation in the children due to receive treatment in adolescence. However, there was no evidence of a difference in the over jet between the groups at the end of treatment. The incidence of incisal trauma was, however, statistically significantly reduced in the two-phase treatment group, the adolescent treatment group having twice the incidence of incisal trauma (47/120) compared to the young children group (27/117).Two trials (n = 282) compared different types of appliances (headgear and functional appliance) for early (two-phase) treatment. At the end of the first phase of treatment statistically significant differences, in favour of functional appliances, were shown with respect to final over jet only. At the end of phase two, there was no evidence of a difference between appliances with regard to over jet, PAR score or the incidence of incisal trauma.Late orthodontic treatment for adolescents with functional appliances showed a statistically significant reduction in over jet of -5.22 mm (95% CI -6.51 to -3.93, P < 0.00001) and ANB of -2.37° (95% CI -3.01 to -1.74, P < 0.00001) when compared to no treatment (very low quality evidence).There was no evidence of a difference in over jet when Twin Block was compared to other appliances. However, a statistically significant reduction in ANB (-0.63°, 95% CI -1.17 to -0.08, P = 0.02) was shown in favour of Twin Block. There was no evidence of a difference in any reported outcome when Twin Block was compared with modifications of Twin Block. CONCLUSIONS: The evidence suggests that providing early orthodontic treatment for children with prominent upper front teeth is more effective in reducing the incidence of incisal trauma than providing one course of orthodontic treatment when the child is in early adolescence. There appear to be no other advantages for providing treatment early when compared to treatment in adolescence.

Lack of reliable evidence of the effectiveness of remineralising agents for the treatment of post orthodontic white spot lesions.

DATA SOURCES: PubMed, Medline, Web of Science and the Cochrane Library databases were searched. STUDY SELECTION: Selection was conducted independently by two reviewers, only randomised controlled trials were included. Study quality was assessed using the Cochrane risk of bias approach. DATA EXTRACTION AND SYNTHESIS: Data abstraction was carried out independently by two reviewers and qualitative summary presented, because of the heterogeneity of the interventions and outcome measures. RESULTS: Seven studies were included, all except one (of medium risk) were considered to be at high risk of bias. Three studies evaluated fluoride preparations (50-ppm sodium fluoride mouth rinse, 5% sodium fluoride varnish and 0.5% sodium fluoride chewing sticks). Four compared remineralising agents containing casein phosphopeptide amorphous calcium phosphate or casein phosphopeptide amorphous calcium fluoride phosphate. CONCLUSIONS: Based on the literature, there is a lack of reliable evidence to support the effectiveness of remineralising agents for the treatment of post orthodontic white spot lesions.

Co-axial computed tomography for optimizing orthodontic miniscrew implant size and site of placement.

PURPOSE: Absolute anchorage has been a critical aspect in orthodontics. Quantity and quality is a critical factor MSI placement. The present study was designed using a spiral computed tomography to assess the bone availability and clinically assess the optimized position and site for MSI placement in the posterior region. MATERIAL AND METHODS: Spiral computed tomography images often patients were obtained with requirement of MSI placement. Mesiodistal inter-radicular distance in the posterior region of the maxilla over narrowest inter-radicular space was measured at 2, 4, 6 and 8 mm from cementoenamel junction. RESULTS: In the maxilla, the greatest inter-root distance was observed between the first molar and the second premolar at the 8-mm level from the CEJ. The inter-root distances at 4, 6, and 8 mm were significantly larger than the distance at 2 mm, showing a gradual increment as the level approaches the root apex. CONCLUSION: The optimal site for placement of a frequently used MSI (diameter 1.8 to 2.0 mm) in between 2nd premolar--1st molar could be 4 mm from the CEJ and between 1st molar--2nd molar be 6 mm from the CEJ.

Miniscrew design and bone response: defining a correlation.

AIM: This prospective clinical trial aims at correlating miniscrew implant (MSI) micro/macro architecture, the method of placement, and biologic markers in peri-MSI crevicular fluid (PMICF) as indicators of bone response. A comparative evaluation of surface morphology of the MSIs before placement and after retrieval defines a correlation between the architecture of the MSIs and the bone- implant contact ratio. METHODS: Two types of MSIs (hybrid and cylindric) were placed in ten patients using a split-mouth technique with the aid of a restricted random number table. Each of the MSIs was placed in the intraradicular area between the second premolar and first molar in the attached gingiva, 4 mm from the cementoenamel junction. The MSIs were immediately loaded, and PMICF was collected on days 0, 7, 14, 21, 28, and 42 and evaluated using a standard laboratory protocol. Surface morphology before placement and after retrieval of the MSI was observed using scanning electron microscopy (SEM) at a magnification of ×11, ×40, and ×1,000. RESULTS: Alkaline phosphatase (ALP) and aspartate aminotransferase (AST) levels observed were lower in the hybrid MSI in comparison to the cylindric MSI. For both MSIs, ALP and AST levels showed a trend of significant increase at days 0, 7, and 14 and then a significant decrease on days 21, 28, and 42. Observations from SEM showed an oxide layer over the entire surface of the bone-expanding hybrid MSI; this layer was observed only at the tip of the cylindric MSI. CONCLUSIONS: Levels of both the diagnostic tissue destruction biologic markers ALP and AST are significantly higher in cylindric MSIs compared with hybrid MSIs, indicating a correlation to the type and method of placement of the MSI. The inflammatory markers show a definitive trend, with an elevation until day 14 and a decline after that, indicating an active inflammatory process until day 14 that could be correlated to tissue trauma. Observations from the SEM show a greater oxide layer formation in the hybrid MSI, which could imply a better bone-MSI contact ratio.

Evidence that of orthodontics improves long term psychological well being lacking.

DESIGN: Cohort study. EXPOSURE: Children who were examined in 1988/1989 were invited to a follow-up in 2005/2006. Respondents completed a questionnaire, which collected information on quality of life, receipt of orthodontic treatment and psychosocial factors, and were invited for a clinical examination. Oral health conditions including occlusal status using the Dental Aesthetic Index were recorded. DATA ANALYSIS: Descriptive statistics, bivariate analysis, analysis of variance and multivariate analyses using linear regression were conducted to determine the effects of various factors on the psychosocial outcomes of orthodontic treatment. RESULTS: No statistically significant association between occlusal status at adolescence and quality of life at adulthood was found. Individuals who had orthodontic treatment but did not need orthodontic treatment had higher self-esteem and were more satisfied with life than other treatment groups. Occlusal status at adulthood was significantly associated with quality of life. Multivariate analyses showed a statistically significant association between occlusal status at adolescence and adulthood with quality of life. Orthodontic treatment was negatively associated with psychosocial factors fixed orthodontic treatment and self-esteem. CONCLUSIONS: Occlusal status appears to have limited association with quality of life and psychosocial factors. Receipt of fixed orthodontic treatment does not appear to be associated with oral health related quality of life but appears to be negatively associated with self-esteem and satisfaction with life.

Redefining orthodontic space closure: sequential repetitive loading of the periodontal ligament--a clinical study.

AIMS: To assess the rate of tooth movement, anchorage loss, root resorption, and alkaline phosphatase (ALP) activity in the gingival crevicular fluid (GCF) as a marker for bone remodeling during orthodontic space closure using two different mechanisms. METHODS: Space closure was completed in 20 patients with extraction of all 4 premolars. Lateral cephalograms and radio-visiographs taken before (T1) and after (T2) space closure were assessed for anchorage loss and root resorption. Alkaline phosphatase levels were measured in 10 patients, which were divided into two groups of five each. Spaces were closed with a screw device in the first group and with active tie-backs in the second. Gingival crevicular fluid samples, collected at intervals, were assayed for alkaline phosphatase spectrophotometrically in each patient. RESULTS: The mean rate of tooth movement was 1.32 ± 0.22 mm/month. The mean amount of anchorage loss in the maxilla and mandible was 1.23 ± 0.60 mm and 1.08 ± 0.65 mm, respectively. Sixty (25%) roots showed no root resorption, while 180 (75%) roots displayed mild to moderate blunting of their apices. Gingival crevicular fluid-alkaline phosphatase level increased significantly from day 7 to day 28 in both groups, but significantly more in the screw retraction group (P<.05). CONCLUSION: It is possible to infer that space closure occurs more rapidly with sequential repetitive loading of the periodontal ligament than with conventional active tie-backs. This observation is in concurrence with a significant increase in the gingival crevicular fluid-alkaline phosphatase level.

Oral health promotion programmes during orthodontic treatment beneficial.

DATA SOURCES: The Cochrane Central Register of Controlled Trials, Medline and Embase databases were searched. A hand search was made of the American Journal of Orthodontics and Dentofacial Orthopaedics, (British) Journal of Orthodontics, European Journal of Orthodontics and Angle Orthodontist, Google Scholar and the reference lists of relevant articles. STUDY SELECTION: Only randomised controlled trials (RCT) and quasi-randomised controlled clinical trials (CCT), which specifically stated that they assessed reductions in dental plaque levels and/ or gingival bleeding when comparing oral health promotion (OHP) interventions, were included. Trials that involved plaque removal by a professional (except at baseline) or the use of proprietary antiplaque agents were excluded. DATA EXTRACTION AND SYNTHESIS: Data extraction was carried out independently by two reviewers. Study quality was assessed for their method of allocation, concealment of allocation, masking of assessment and reporting of withdrawals. Direct comparison between the trials was difficult because of the heterogeneity in the outcome measures between the included studies. RESULTS: Six RCT and quasi-randomised CCT met the inclusion criteria. Positive effects on plaque and/ or gingival health were produced in only four of the included trials. OHP did not result in any detectable difference in two of the included trials. None of the trials that were included produced a negative effect of orthodontic OHP on oral hygiene and gingival health. CONCLUSIONS: An OHP programme for people undergoing fixed appliance orthodontic treatment produces a short-term reduction (of up to 5 months) in plaque and improvement in gingival health. No particular OHP method produced a greater short-term benefit to periodontal health during fixed appliance orthodontic treatment. Further studies using appropriate methods and, in particular,r longer followup periods are required.

Soft tissue changes associated with first premolar extractions in adult females.

BACKGROUND: The potential for premolar extractions to produce changes in the soft tissue profile after orthodontic treatment is controversial. AIM: To evaluate the soft tissue changes associated with four first premolar extractions in adult females of South Indian ethnicity. METHOD: Pre- and post-treatment lateral cephalometric radiographs of 30 adult female patients of South Indian ethnicity with bimaxillary dentoalveolar protrusion, requiring premolar extractions as a part of their orthodontic treatment, were used. The radiographs were traced and changes in three angular and 12 linear measurements measured relative to the perpendicular to the horizontal reference line, 7 degrees down from S-N through S. Correlation coefficients between the changes in the upper and lower incisors and the lip measurements were calculated. RESULTS: All linear and angular measurements, except for changes in upper and lower lip thickness, B' point and the anterior point on the lower lip, showed statistically significant (p < 0.05) changes with treatment. A significant negative correlation was found between upper incisor change and nasolabial angle change and a significant positive correlation was found between upper incisor change and retraction of the most anterior point on the upper lip. CONCLUSION: Extraction of the four first premolars followed by the retraction of incisors reduced the dental and soft tissue protrusion found in adult South Indian females with bimaxillary dentoalveolar protrusion.

Medication and tooth movement.

DATA SOURCES: PubMed, Embase, Web of Science and Biosis were used to search for relevant material, along with the reference lists of retrieved articles. STUDY SELECTION: Both animal and clinical studies were included if they met the following criteria: they had study and control groups of at least five subjects each; used drugs or supplements with known effects on bone physiology; recorded drug dose and administration; gave details of the application of the forces used for tooth movement; described the technique used to measure the rate of tooth movement; and presented a statistical analysis of the results of the study. DATA EXTRACTION AND SYNTHESIS: A formal data extraction process is not described. RESULTS: Forty-nine studies were included in this review. Numerous problems were found in the information presented in the reviewed literature from the almost exclusively animal studies. Comparison of the data from these studies was difficult because of the variability in experimental design, animal models, administration regimens, application and duration of forces to the teeth involved. CONCLUSIONS: The authors identified a need for more well designed studies on the effects of various types of medication on orthodontic tooth movement.

Soft-tissue cephalometric norms in a South Indian ethnic population.

INTRODUCTION: An esthetically pleasing smile is a key determinant of successful orthodontic treatment and patient satisfaction. The great variance in soft-tissue drape of the human face complicates accurate assessment of the soft-tissue profile. Variability is also characteristic of different faces and facial types, and normative data based on 1 population group do not represent all. This study was undertaken to establish norms for a South Indian ethnic population. METHODS: The sample comprised lateral cephalograms taken in natural head position of 60 normal subjects (30 men, 30 women). The cephalograms were analyzed with a soft-tissue cephalometric analysis for orthodontic diagnosis and treatment planning, and the Student t test was used to compare the means of the 2 groups. RESULTS: Statistically significant differences were found between South Indian men and women in certain key parameters. Men have thicker soft-tissue structures and a more acute nasolabial angle than women. Men have longer faces, and women have greater interlabial gap and maxillary incisor exposure. Men have more deep-set facial structures than women. Compared with established norms for white people, South Indian subjects have more deep-set midfacial structures and more protrusive dentitions. CONCLUSIONS: Statistically significant differences were found between South Indian men and women in certain key parameters. Differences were also noted between white and South Indian faces.

Is anchorage reinforcement with implants effective in orthodontics?

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase were searched. No language restrictions were applied. Authors were identified and contacted to identify unpublished trials. STUDY SELECTION: Studies selected were randomised clinical trials (RCT) or quasi-RCT involving surgically assisted means of anchorage reinforcement in orthodontic patients. DATA EXTRACTION AND SYNTHESIS: Data extraction was performed by two review authors working independently using a previously piloted data collection form. Data were entered into RevMan (The Nordic Cochrane Centre. Copenhagen, Denmark); planned analysis of mean differences and 95% confidence intervals (CI) for continuous outcomes, and risk ratios (RR) and 95% CI for dichotomous outcomes. Pooling of data and meta-analysis were not performed because there were too few similar studies. RESULTS: To date, few trials have been carried out in this field and there are insufficient data of adequate quality in the literature to meet the objectives of the review. The review authors were only able to find one study that assessed the use of surgical anchorage reinforcement systems. This trial examined 51 patients with absolute anchorage requirements treated in two centres. Patients were randomly allocated to receive either headgear or a midpalatal osseo-integrated implant. Anchorage loss was measured cephalometrically by mesial movement of dental and skeletal reference points between the start of treatment and the end of anchorage reinforcement. All skeletal and dental points moved mesially more in the headgear group than the implant group. Results showed significant differences for mesial movement of the maxillary molar in both groups. The mean change in the implant group was 1.5 mm [standard deviation (SD), 2.6; 95% CI, 0.4-2.7] and for the headgear group was 3.0 mm (SD, 3.4; 95% CI, 1.6-4.5). The trial was designed to test a clinically significant difference of 2 mm, so the result was not statistically significant, but the authors conclude that midpalatal implants do effectively reinforce anchorage and are an acceptable alternative to headgear in absolute anchorage cases. CONCLUSIONS: There is limited evidence that osseo-integrated palatal implants are an acceptable means of reinforcing anchorage. The review authors were unable to identify trials addressing the secondary objectives of the review relating to patient acceptance, discomfort and failure rates. In view of the fact that this is a dynamic area of orthodontic practice, there is a need for high-quality RCT. There are financial restrictions in running trials of this nature but it would be in the interest of implant manufacturers to fund such quality, independently conducted trials of their products.

Space closure using the Hycon device. A case report.

BACKGROUND: Space closure can be a difficult and uncomfortable procedure. Appliances able to be activated by the patient may reduce the number of visits for adjustment. OBJECTIVE: To describe the closure of spaces with the Hycon device, an intra-oral screw that can be activated by the patient. METHOD: Sliding mechanics were used to retract the upper and lower anterior teeth following extraction of the first premolars in a patient with bimaxillary protrusion. The active force for retraction was derived from the Hycon device activated twice a week by the patient. RESULTS: The rate of space closure achieved was of the order of 1.9 mm/month. The extraction spaces were closed by distal movement of the anterior teeth and mesial movement of the posterior teeth. CONCLUSION: The Hycon device proved to be an effective means of retracting the anterior teeth and protracting the posterior teeth. Because the device can be activated by the patient fewer visits for adjustment may be required.