Spectrum of positional deformities - is there a real difference between plagiocephaly and brachycephaly?

AIM: This study analyses pathomorphological and physiological head shapes and classifies the pathomorphology in positional plagiocephaly and brachycephaly. PATIENTS AND METHODS: 78 infants with a positional plagiocephaly (5.99 months) and 32 infants with a positional brachycephaly (6.53 months) with a Cephalic index > 94% were investigated in this study and compared to a matched control group of 35 infants. The head shapes were analysed by stereophotogrammetry 3D data. RESULTS: The cephalic index, the total width, and coronal circumference were the highest values in patients with brachycephaly and the lowest values in the control group. The asymmetry of the head showed that the diagonal difference in brachycephalic patients more than doubled, and in patients with plagiocephaly almost tripled compared to the controls. A significantly higher total volume and vertex height was found for the patients with plagiocephaly and the patients with brachycephaly compared to the controls. CONCLUSION: The cephalic index is a valuable and reliable parameter in order to differentiate positional deformities from unaffected skulls. Pathomorphology of a plagiocephaly is associated with the most severe asymmetry of the head. Plagiocephaly and brachycephaly overlap in several criteria. Therefore it seems justified to speak of a continuum rather than to differentiate between plagiocephaly and brachycephaly.

3D stereophotogrammetric analysis of operative effects after broad median craniectomy in premature sagittal craniosynostosis.

INTRODUCTION: There is ongoing discussion on the diagnostic methods, the need of surgical treatment, and the surgical strategies for premature craniosynostosis. MATERIALS AND METHODS: This study examined the operative procedure of a standardized broad median craniectomy, active tilting of the forehead, and bitemporal greenstick fracturing in children with premature sagittal craniosynostosis. To objectively analyze the direct surgical results, we used a 3D stereophotogrammetry scanner, as previously described. RESULTS: A 3D analysis showed a significant increase in the width, cranial index (CI), head and coronal circumferences, intracranial volume, and cranial base width after surgery. Head length was the only parameter that demonstrated a significant decrease postoperatively. Asymmetry and the 30° diagonal difference showed no significant changes. CONCLUSION: 3D stereophotogrammetry is a reliable and valuable tool with no side effects. It demonstrated that the extended surgical procedure achieves good postoperative results with a reduced length and increased width and, therefore, an improved CI. Additionally, the total intracranial volume was significantly increased after surgery.

Short-term pharyngeal airway changes after mandibular advancement surgery in adult Class II-Patients--a three-dimensional retrospective study.

The purpose of this study was to investigate volume changes in posterior airway space (PAS) after bilateral mandibular advancement surgery. Measurements were taken based on three-dimensional (3D) records available for a large and homogeneous cohort of patients. Pre- and postoperative CBCT scans of 102 adult patients with Class II dysgnathia were visualized and analyzed using 3D software (Mimics® Innovation Suite 14.1; Materialise, Leuven, Belgium). The PAS was divided into three segments by three planes parallel and one plane perpendicular to the Frankfort horizontal plane. Total volume, partial volumes, and cross-sectional areas were calculated from the pre- and postoperative scans. Dahlberg coefficients were obtained to verify each parameter for the measurements' reliability. The statistical significance of the changes observed was analyzed by Wilcoxon's rank-sum test. Highly significant (p=0.000) increases in total posterior airway volume (+32.0%) were noted as an effect of mandibular advancement surgery, amounting to 45.6% in the lower PAS third compared to 38.8% in the middle and 12.5% in the upper PAS third. We also obtained highly significant (p=0.000) increases in all the cross-sectional areas investigated, amounting to 48.5% on the soft-palate level compared to 21.6% on the level of the epiglottis tip, and 14.6% on the hard-palate level. These results demonstrate that bilateral mandibular advancement surgery in Class II-Patients leads to significant increases in PAS volume and significant widening of the narrower sites inside the pharynx.

The impact of spur therapy in dentoalveolar open bite.

AIM: A longitudinal casecontrol study, designed to analyse the isolated effect of attached palatal spurs in patients displaying a dentoalveolar anterior open bite, is presented. METHODS: Thirty-one patients (mean age of 13.3 years +/- 3.17 years) underwent a standardised treatment protocol with fixed anterior spurs for 8.3 months. Lateral cephalograms and plaster casts were analysed before (T1) and after spur therapy (T2). The data were tested using paired t-tests with a significance level of p < 0.05. RESULTS: The cephalometric analysis showed significant elongation of the height of the maxillary (mean +1.22 mm) and the mandibular (mean +1.39 mm) alveolar processes, as well as uprighting of the lower anterior teeth. The plaster cast analysis showed an increase in maxillary intermolar width (mean +0.98 mm) and a decrease in intercanine distance (mean -0.96 mm). The mandibular anterior width and dental arch length reduced. Overall, spur therapy resulted in a significant increase in overjet and overbite. CONCLUSION: The use of spurs produced a resolution of the open bite in all patients. Therefore, spurs could be considered an effective mechanism for the management of anterior open bite in selected adolescent patients.

Three-dimensional perception of facial asymmetry.

In orthodontic diagnosis, facial symmetry is important. The aim of the present study was to analyse the perception of various degrees of facial asymmetry exhibited by carefully designed virtual three-dimensional (3D) material. Three groups of raters (30 orthodontists, 30 maxillofacial surgeons, and 30 laymen) rated, using a six-point scale, the degree of asymmetry of eight randomly presented 3D faces exhibiting incremental soft tissue alterations. The faces were created by gradually transforming the nose or chin in increments of 2 mm away from the computed symmetry plane. Differences between the groups in analysis of facial asymmetry, the rating of facial stimulus, and right and left facial asymmetry were determined using a t-test. The results demonstrated that raters' profession did not influence the point at which they identified asymmetry. Even laymen were able to detect asymmetries when located near the midline of 3D faces. All raters identified asymmetries of the nose as more negative than those of the same degree of the chin. A left-sided deviation of the nose along the facial symmetry plane lead to a more negative rating of facial appearance, whereas a right-sided deviation of the chin was rated as less attractive. Nasal architecture plays a crucial role in the perception of symmetry. These findings provide clinicians with a greater understanding of how faces are perceived, a process which is of particular interest in treating orthognathic patients, and those with congenital anomalies.

New model for surgical and nonsurgical therapy in adults with Class III malocclusion.

INTRODUCTION: Not all adult Class III malocclusion patients are candidates for surgical correction. In patient assessment and selection, major issues remain regarding diagnosis and treatment planning. The purpose of this investigation was to ascertain whether adding a transverse parameter to a discriminant analysis could improve the classification of adults with Class III malocclusion into 2 groups of patients: those who can effectively be treated by orthodontic therapy and those who require orthognathic surgery. METHODS: Cephalograms, plaster casts, and extraoral photos of 69 adults with Class III malocclusion were analyzed. A discriminant analysis was performed to identify the variables that best separate the 2 groups. RESULTS: Stepwise variable selection resulted in a new, highly significant (P <0.0001) model of 4 variables that provided the best discriminant function to distinguish between patients with and without indications for surgical correction. The resulting equation was the following: score = -10.988 + 0.243 * Wits + 0.055 * M/M ratio + 0.068 * NSAr - 0.589 * mand MLD. The percentage of patients correctly classified by this equation was 91.3%. The sensitivity was 0.92, and the specificity was 0.89. CONCLUSIONS: In the discriminant analysis, the mandibular midline deviation as a transverse component was included. The addition of the transverse variable led to an improved model concerning the predictive value in Class III malocclusion patients with surgical requirements.

Face perception in patients with unilateral cleft lip and palate and patients with severe Class III malocclusion compared to controls.

Although there is principal agreement that increased facial asymmetry is associated with decreased facial attractiveness, there are no studies analysing face perception in patients with a unilateral cleft lip and palate (CLP) (uCLP) compared to orthognathic Class III patients. To this end, three-dimensional (3D) data on the faces of 30 adults with a complete uCLP, 20 orthognathic patients with a severe skeletal Class III, and 20 adults with a skeletal Class I as a control group were generated. The 3D asymmetry of the facial soft-tissue was analysed. These data were compared with subjective ratings for attractiveness carried out by 100 laypersons. Compared to the controls, uCLP patients and orthognathic patients had a significantly higher facial asymmetry. No difference was found between uCLP patients and orthognathic patients. The attractiveness ratings showed that uCLP patients and orthognathic patients were rated less attractive compared to the controls. However, although there were no differences in the facial asymmetry between uCLP patients and orthognathic patients, the uCLP patients were rated significantly less attractive. This leads to the conclusion that not only the extent of asymmetry has an influence on attractiveness but also the location of asymmetry. For clinical use, these findings underline the importance of accurate as possible surgical reconstruction of the nasal morphology in uCLP patients.

Treatment modalities of infants with upper airway obstruction--review of the literature and presentation of novel orthopedic appliances.

OBJECTIVE: To present a new orthopedic method for treatment of infants with Pierre Robin sequence (PRS) and upper airway obstruction (UAO) as an alternative to other established nonsurgical and surgical techniques such as positioning, nasopharyngeal or endotracheal intubation, tongue-lip adhesion, extension, distraction, or tracheostomy. DESIGN: Review of the literature and presentation of novel orthopedic appliances. SETTING: Department of Orthodontics, Dental Clinic, Medical Faculty of the University of Wuerzburg, Germany, Department and Clinic of Pediatrics, Medical Faculty of the University of Wuerzburg, Germany, 2005 to 2008. PATIENTS: Seven patients with significant respiratory and feeding difficulties between 0 and 6 months of age. Both patients with nonsyndromic PRS and patients with syndromic PRS were included. INTERVENTIONS: The type of respiratory tract obstruction was defined by nasopharyngoscopy. Patients with type 1 obstruction received a plate with an epiglottic spur; whereas, patients with obstruction type 2, 3, or 4 received a plate with a pharyngeal tube. RESULTS: All patients were successfully treated with orthopedic appliances alone. Under plate therapy they showed good oxygen saturation and could consequently be better nourished orally. CONCLUSIONS: The presented novel method is a noninvasive technique in treatment of infants with UAO.

3D soft tissue analysis--part 2: vertical parameters.

INTRODUCTION: The increasing relevance of 3D methods in orthodontic diagnostics and treatment planning calls for the development of new analysis methods and the definition of three-dimensional mean values. OBJECTIVE: The aim of this study was to develop a reliable three-dimensional (3D) analysis of facial soft tissues. Our objectives were to determine vertical 3D mean values and define the relationship between vertical skeletal parameters and digitally-recorded 3D soft tissue parameters. PATIENTS AND METHODS: A total of 100 adult patients (female symbol = 53, male symbol = 47) of Caucasian ethnic origin were included in the study. Patients with syndromes, cleft lip and palate, noticeable asymmetry or anomalies in the number of teeth were excluded. Arithmetic means for three vertical 3D soft tissue parameters were calculated. The parameters were analyzed biometrically in terms of their reliability and gender-specific differences. Furthermore, the 3D soft tissue values were analyzed with regard to any correlations with vertical cephalometric values. In addition, we employed stepwise discriminant analysis, a multivariate statistical method, to examine the extent to which correct assessment of craniofacial morphology is possible by referring to those 3D parameters. RESULTS: We successfully defined reproducible 3D mean values for the 3D soft tissue parameters, demonstrating highly significant correlations between the vertical 3D soft tissue measurements and cephalometric measurements. 89.8% of the patients could be correctly assigned to a vertical or horizontal craniofacial morphology according to the 3D soft tissue values. CONCLUSION: 3D soft tissue analysis provides information about vertical skeletal parameters, allowing assessment of vertical craniofacial morphology. Further investigation will be required so that 3D soft tissue diagnosis can be integrated into treatment planning and assessment as a supportive diagnostic tool in the future.

3D soft tissue analysis--part 1: sagittal parameters.

OBJECTIVE: The aim of this study was to develop a reliable three-dimensional (3D) analysis of facial soft tissues. We determined the mean sagittal 3D values and relationships between sagittal skeletal parameters, and digitally recorded 3D soft tissue parameters. PATIENTS AND METHODS: A total of 100 adult patients (n(female) = 53, n(male) = 47) of Caucasian ethnic origin were included in this study. Patients with syndromes, cleft lip and palate, noticeable asymmetry or anomalies in the number of teeth were excluded. Arithmetic means for seven sagittal 3D soft tissue parameters were calculated. The parameters were analyzed biometrically in terms of their reliability and gender-specific differences. The 3D soft tissue values were further analyzed for any correlations with sagittal cephalometric values. RESULTS: Reproducible 3D mean values were defined for 3D soft tissue parameters. We detected gender-specific differences among the parameters. Correlations between the sagittal 3D soft tissue and cephalometric measurements were statistically significant. CONCLUSION: 3D soft tissue analysis provides additional information on the sagittal position of the jaw bases and on intermaxillary sagittal relations. Further studies are needed to integrate 3D soft tissue analysis in future treatment planning and assessment as a supportive diagnostic tool.