Treatment of a severe Class II Division 1 malocclusion combined with surgical miniscrew anchorage.

This article reports the camouflage treatment of a female patient, aged 15 years 2 months, who had a Class II Division 1 malocclusion with severe anterior protrusion and deep incisor overbite. The camouflage treatment plan included bilateral extraction of the maxillary first premolars combined with the use of temporary anchorage devices (TADs) and tension coil springs to retract canines into the extraction spaces and then the 4 incisors. The treatment included use of a mandibular fixed labial arch with minimal use of Class II elastics to correct mild mandibular spacing and level the curve of Spee. Ideal overjet and overbite relationships were established, and the final result was well balanced and esthetically pleasing. The molars were finished in a Class II relationship. Total treatment time was 2 years 6 months. Cephalometric superimpositions revealed that mandibular molars were not disturbed by the limited use of Class II elastics. Surgical miniscrews in canine and incisor retraction in Class II Division 1 malocclusion are an alternate type of temporary anchorage that reduce or remove reliance on conventional intermaxillary anchorage.

Soft tissue molding technique in cleft lip and palate patient using laser surgery in combination with orthodontic appliance: A case report.

BACKGROUND: Although surgical treatment protocols for cleft lip and palate patients have been established, many patients still have some soft tissue defects after complete healing from surgical interventions. These are excess soft tissue, high attached fraena and firmed tethering scares. These soft tissue defects resulted shallowing of vestibule, restricted tooth movement, compromised periodontal health and trended to limit the maxillary growth. The aim of this case report was to present a method of correcting soft tissue defects after conventional surgery in cleft lip and palate patient by using combined laser surgery and orthodontic appliance. CASE REPORT: A bilateral cleft lip and palate patient with a clinical problem of shallow upper anterior vestibule after alveolar bone graft received a vestibular extension by using CO2 laser with ablation and vaporization techniques at 4 W and continuous wave. A customized orthodontic appliance, called a buccal shield, was placed immediately after surgery and retained for 1 month to 3 months until complete soft tissue healing. The procedures were performed 2 episodes. Both interventions used the same CO2 laser procedure. The first treatment resulted in partial re-attachment of soft tissue at surgical area. The second laser operation with the proper design of buccal shield providing passive contact with more extended flange resulting in a favorable outcome from 1 year follow up. Then the corrective orthodontic treatment could be continued effectively. CONCLUSION: The CO2 laser surgery was a proper treatment for correcting soft tissue defects and the design of buccal shield was a key for success in molding surgical soft tissue.

Evaluation of Facial Appearance among Patients With Repaired Unilateral Cleft Lip and Palate: Comparison of Patient- and Clinician-Ratings of Satisfaction.

The objective of this study was to determine the levels of patient-satisfaction on facial and dental appearance compared with clinician ratings. Participants included 61 patients with repaired unilateral cleft lip and palate (UCLP), aged 14-25 years. Raters comprised three cleft team clinicians. A Likert scale was used to assess the levels of satisfaction of the patients themselves and the clinicians. The results revealed that the patients were moderately satisfied with their appearance. Nose was the least satisfactory feature, followed by lip appearance. When compared to the clinician ratings, the patients were less satisfied with their own nose and lip, but more satisfied with teeth. Concerning age, self-assessment did not differ between adolescents and young adults. Females were less likely to be satisfied compared to males, but the difference was not statistically significant. In conclusion, patients with repaired UCLP were moderately satisfied with their facial and dental appearance. Clinician- and patient-opinions were different in some aspects. This study highlights the importance of patient satisfaction as a meaningful treatment outcome assessment, which could lead to an improvement in cleft care to meet the patient expectations.

Agreement of Tracing and Direct Viewing Techniques for Cervical Vertebral Maturation Assessment.

OBJECTIVE: This study aimed to evaluate agreement among three methods for cervical vertebral maturation (CVM) assessment, comprising direct viewing, tracing only, and tracing with digitized points. MATERIAL AND METHOD: Two examiners received training and tests of reliability with each CVM method before evaluation of agreement among methods. The subjects were 96 female-cleft lateral cephalometric radiographs (films of eight subjects for each age ranged from seven to 18 years). The examiners interpreted CVM stages of the subjects with four-week interval between uses of each method. RESULTS: The range of weighted kappa values for paired comparisons among the three methods were: 0.96-0.98 for direct viewing and tracing only comparison; 0.93-0.94 for direct viewing and tracing with digitized points comparison; and 0.96-0.97 for tracing only and tracing with digitized points comparison. The intraclass correlation coefficient (ICC) value among the three methods was 0.95. These results indicated very good agreement among methods. CONCLUSION: Use of direct viewing is suitable for CVM assessment without spending more time for tracing. However, the three methods might be used interchangeably.

Oral Health-Related Quality of Life in Children and Young Adolescent Orthodontic Cleft Patients.

OBJECTIVE: To evaluate and compare the oral health-related quality of life (OHRQoL) in Thai patients with cleft lip and palate and to evaluate parents' and their children perceptions. MATERIAL AND METHOD: Child Oral Health Impact Profile (COHIP) questionnaire was used to evaluate OHRQoL of the patients and parents' perceptions of patients' OHRQoL. The subjects consisted of 140 cleft patients (aged 8-15 years) and their parents who visited the Department of Orthodontics, Khon Kaen University. RESULTS: COHIP scores in cleft patients were relatively high. No statistically significant differences were found for overall and subscales COHIP scores between gender and age groups (aged 8-11 and 12-15 years) of patients. Comparison among cleft types, overall COHIP and functional well-being subscales scores showed statistically significant differences (p = 0.01 and p = 0.002, respectively). Cleft lip with or without alveolus (CL/A) had higher overall and functional well-being subscale scores than unilateral and bilateral cleft lip and palate patients (CLP). Only self-image subscale scores were statistically significant differences between patients and parents at p<0.001. CONCLUSION: Young and adolescent patients with cleft lip and palate had generally positive oral health-related quality of life. Impacts of gender and age of patients on OHRQoL were similar CL/A patients had more positive in overall oral health-related quality of life and functional well-being domains than CLP patients did. Parents had higher perceptions of self-image shown by their children than the children themselves.

Orthodontic Treatment Combined with Orthognathic Surgery and Simultaneous Alveolar Bone Graft of a Unilateral Complete Cleft Lip and Palate Patient: A Case Report.

This article aimed to present a case of 22 year-old Thai female with cleft lip and palate who had malocclusion developed from dental problems, skeletal disharmony and unrepaired alveolar cleft. The treatment was orthodontic combined with one-stage surgical correction which corrected skeletal discrepancy and alveolar cleft in single operation. After treatment, the patient had improved in facial esthetics, attaining good occlusal function and continuous maxillary dental arch. This procedure can reduce morbidity, preclude a second hospitalization and the cost of two-stage surgical correction. However this is only an alternative treatment for adult cleft patients who need late alveolar bone graft and orthognathic surgery.

Pre-surgical nasoalveolar molding technique: a literature review.

Cleft lip and palate patients have many defects particularly nasal deformities. The nasoalveolar molding (NAM) technique is an adjunctive treatment, which not only corrects deviated alveolar segments but also addresses nasal deformity before cheiloplasty. NAM technique is claimed to facilitate primary surgical correction and to provide favorable esthetic outcomes. However, there is limited evidence to confirm the special benefits ofNAM technique since so far there have been no truly long term controlled clinical trials to evaluate outcomes of treatment based on pre-surgical NAM technique. NAM technique can aid surgeons in their primary repairs ofnasal deformities but there should be concern about cost-risk benefits and ability ofparents to manage home care. Further studies based on properly designed and managed long-term clinical trials are still neededfor reaching consensus on special benefits ofNAM technique compared with other treatment protocols.

A comparison of cervical vertebral maturation assessment of skeletal growth stages with chronological age in Thai between cleft lip and palate and non-cleft patients.

OBJECTIVE: (1) To search for any difference in chronological age related to stages of the cervical vertebral maturation index stages (CVMIs) comparing groups of cleft lip and palate (CLP) and non-cleft (non-CLP) subjects; (2) To investigate the relationship between chronological age and CVMIs in both groups of subjects. MATERIAL AND METHOD: Cervical vertebrae C2, C3, C4 were assessed on 1,549 cephalometric films (503 CLP films, 1,046 non-CLP films of subjects aged 5 to 18 years) using Hassel and Farman's method. RESULTS: T-tests showed mean chronological ages of CVMIs 2, 3 and 6 were different at p = 0.001, 0.024 and 0.016, respectively. CVMIs 1, 4 and 5 showed no significant differences. The CLP group achieved each CVMI score one year ahead of the non-CLP group, except for CVMI 4. Spearman's rank order correlations were r = 0.80 (95% CI: 0.76-0.83) for CLP, and 0.77 (95% CI: 0.74-0.79) for non-CLP. CONCLUSION: CLP subjects tended to have a slightly advanced growth compared with non-CLP subjects. A high correlation coefficient was found between chronological age and cervical vertebral skeletal maturation.

Comparative study between the hand-wrist method and cervical vertebral maturation method for evaluation skeletal maturity in cleft patients.

OBJECTIVE: To test the measure of agreement between use of the Skeletal Maturation Index (SMI) method of Fishman using hand-wrist radiographs and the Cervical Vertebral Maturation Index (CVMI) method for assessing skeletal maturity of the cleft patients. MATERIAL AND METHOD: Hand-wrist and lateral cephalometric radiographs of 60 cleft subjects (35 females and 25 males, age range: 7-16 years) were used. Skeletal age was assessed using an adjustment to the SMI method of Fishman to compare with the CVMI method of Hassel and Farman. Agreement between skeletal age assessed by both methods and the intra- and inter-examiner reliability of both methods were tested by weighted kappa analysis. RESULTS: There was good agreement between the two methods with a kappa value of 0.80 (95% CI = 0.66-0.88, p-value <0.001). Reliability of intra- and inter-examiner of both methods was very good with kappa value ranging from 0.91 to 0.99. CONCLUSION: The CVMI method can be used as an alternative to the SMI method in skeletal age assessment in cleft patients with the benefit of no need of an additional radiograph and avoiding extra-radiation exposure. Comparing the two methods, the present study found better agreement from peak of adolescence onwards.

Prevalence and types of dental anomaly in a Thai non-syndromic oral cleft sample.

OBJECTIVE: To investigate the prevalence and characteristics of dental anomalies (DAs); missing teeth (MT), dens-evaginatus (D-E), dens-invaginatus, dilaceration,fusion, gemination, macrodontia, microdontia (Micro), supernumerary teeth (SNT), and taurodontism, in permanent teeth among subjects with non-syndromic oral cleft. MATERIAL AND METHOD: This cross-sectional study was designed to assess DAs from diagnostic records; comprising panoramic radiograph, intraoral photographs, dental casts, and orthodontic clinic charts of 280 Northeastern Thai subjects, mean age 10.3 +/- 3.2 years. Chi-square test was used to compare DA prevalences among cleft phenotypes and genders. RESULTS: There were one or more teeth with DAs in 89.6% of the study population. Highest prevalence was MT (60.4%) followed by Micro (41.4%), dilaceration (6.4%), SNT (6.1%) , and 0.4% in D-E, fusion, gemination, and taurodontism. The most prevalent MT was found in 70.7% of subjects in bilateral cleft lip and palate group. CONCLUSION: The two predominant DAs were MT and Micro, higher prevalences being found with the more severe cleft conditions. The most affected teeth were cleft-site lateral incisors. There were no differences in distribution of DA in male and female.

Alveolar bone graft evaluation agreement using cone beam computed tomography in cleft lip and palate patients: a pilot study.

OBJECTIVE: To develop and test assessor agreement using a new cone beam computed tomography (CBCT) examination method for evaluating the outcome of alveolar bone grafts in cleft lip and palate patients. MATERIAL AND METHOD: Twenty patients with complete cleft lip and cleft palate who had undergone alveolar bone grafting with CBCT follow-up 3-6 months postoperative at the Faculty of Dentistry, Khon Kaen University were recruited into the study. Four trained clinical assessors (two orthodontists, an oral surgeon and an oral radiologist) had made a judgment of three outcome measurements: 1) cemento-enamel junction (CEJ) to marginal bone level of the teeth adjacent to the cleft site, 2) marginal bone level to root apex of the teeth adjacent to the cleft site, 3) labio-lingual alveolar bone grafted thickness. Repeat measurements were made by the same assessors. RESULTS: The Kappa values of intra-assessor agreements of each assessor were 0.82, 0.91, 0.91 and 1, respectively, while the inter-assessor agreements for the first and second time of determinations were 0.81 and 0.74. CONCLUSION: This CBCT method for scoring alveolar bone graft outcomes produced good agreement among four assessors, which suggests its potential use to evaluate the success of alveolar bone grafting. In the future, this new method of alveolar bone graft evaluation should be compared with the standard method for testing validity.

Correction of complete maxillary crossbite with severe crowding using Hyrax expansion and fixed appliance.

An 18-year-old Thai man who presented with a secondary cleft palate, maxillary hypoplasia and severe crowding was treated by rapid maxillary expansion and fixed orthodontic appliances. Initial assessment found skeletal Class III malrelationship and dental Class II malocclusion with anterior and bilateral posterior crossbites. Camouflage orthodontic treatment was planned using a rapid maxillary expansion appliance and correcting crowding with extraction all four premolar teeth. A Hyrax appliance and vertical loop arch wire were placed for maxillary arch expansion of 9.5 mms at first molars and canines, and 5.5 mms at the premolars and obtained positive overjet. Both acceptable skeletal and soft tissue relationships and satisfactory occlusion were produced. After 14 months of postoperative follow-up, the occlusal result was stable and no skeletal reversals could be detected.

Management of bilateral severely impacted mandibular second molars: a case report.

Impaction of the mandibular second molar is relatively rare but when it occurs it may cause a clinical problem for orthodontist and oral surgeon. There are various treatment options to manage this condition depending on the degree of second molar inclination, the position of third molars, and the desired type of tooth movement. Here, a case of orthodontic uprighting of bilateral horizontal impaction of the lower second molars in a 17-years-old Thai female patient is presented. Correction of the impactions involved removal of the overlying third molars and use of full edgewise appliances with open NiTi-coil spring and super-elastic NiTi archwire.

Movement of an upper central incisor across the midline in a patient with cleft of primary palate.

Orthodontic treatment for a 10-years-old girl, with repaired bilateral cleft lip and left incomplete unilateral alveolar cleft, was performed by moving her right maxillary central incisor across the midline to replace her congenital missing central incisor and then moving the right lateral incisor toward the midline to act as a new central incisor. A malformed supernumerary tooth, positioned between the right central and lateral incisor, was extracted during incisor movement. Significant lip profile improvement was accomplished by maxillary and mandibular anterior teeth retraction into three-premolar extraction spaces. Not only natural functional occlusion, deviated midpalatal suture along the central incisor, and no obvious root resorption were obtained but also narrowing the alveolar bone cleft which was beneficial for bone continuity supporting dental structures, satisfactory results were possible for the patient with primary palate cleft.

Orthodontic treatment of unilateral cleft lip and alveolus patient with maxillary lateral incisor missing: case report.

The esthetics of a patient with a cleft lip and alveolus and missing maxillary lateral incisor is important. A girl, aged 9 years 3 months with repaired left unilateral cleft of primary palate only was referred for orthodontic evaluation of her anterior tooth-crowding. She was unhappy with the unattractive appearance of her maxillary anterior teeth, which were behind her mandibular anterior teeth. Alveolar bone grafting along with canine substitution to replace her missing lateral incisor were recommended for this patient. The post-treatment results were excellent with good occlusion, acceptable profile, and remained stable one year after conclusion of active treatment.

Growth modification in unilateral cleft lip and palate patients with face mask.

The intended aim of treatment in cleft lip and palate patients with growth modification is to improve the relation of jaws by advance the maxilla, restrict the mandible or combination of these. The appliances usually used are face mask or protraction headgear (Delaire and Petit types). Modification of growth is advocated to be applied before the end of adolescent growth spurt and long-term and permanent improvement cannot be guaranteed. Achieving the aim of growth modification is still controversial since most reported results of this treatment are dento-alveolar changes and backward rotation of the mandible that would not be considered to be growth modification.

Temporomandibular joint growth adaptation and articular disc positional changes in functional orthopedic treatment: magnetic resonance imaging investigation.

Functional orthopedic appliances have been proposed for the correction of Class II malocclusion due to a retrognathic mandible. The aim of using this appliance is to stimulate mandibular growth by forward positioning of the mandible in order to achieve normal jaw relationship. However, the modes of action using this appliance are still inconclusive. Also the effects of this therapy on the temporomandibular joint (TMJ) are still subject to doubts and discussion. Magnetic resonance imaging (MRI), the gold standard for assessing the soft tissue and position of the TMJ articular disc, therefore, was used to help clarify the effect of this appliance on the TMJ. The aims of this article are to provide a literature review of the methods that are used to assess changes in the TMJ, as seen on MRIs, from functional orthopedic appliances which include condylar and glenoid fossa remodeling assessment, condyle-fossa relationship assessment and articular disc assessment and to review clinical studies using MRI to investigate the effects of functional orthopedic treatment on the TMJ.

Surgery first orthognathic approach for skeletal Class III malocclusion corrections--a literature review.

Management for patients with skeletal Class III malocclusion is orthognathic surgery which involves both orthodontics and surgery. Nowadays, there are two approaches for orthognathic surgery: orthodontics-first and surgery-first approaches. The orthodontics-first approach, or presurgical orthodontics treatment, causes longer treatment time and worsens facial appearance before surgery compared with a surgery-first approach. Conversely, with the surgery-first approach or the surgery-first-orthognathic-approach (SFOA), correction can be resolved more rapidly. SFOA needs high level skill of orthodontist and surgeon and also needs good cooperation between them to accomplish best results. The purpose of this article is to review the concept, indications, contraindications, the stages of treatment and advantages, and disadvantages of SFOA.

Comparison of a clinical method with two radiographic methods for assessing quality of alveolar bone grafts.

The aim of the present study was to test the agreement between a new developed clinical examination method and two commonly used radiographic scales (Bergland and Chelsea) for assessing alveolar bone graft outcomes in the cleft lip and palate patients. This new clinical method consisted of: (1) Probing depth for the teeth adjacent to the cleft and (2) Residual defects at the bone graft site. Two trained examiners examined the subjects in the present study. The inter- and intra-reliability tests of the two clinical criteria and the two radiographic scales produced the excellent agreement level of Kappa values (0.85-1.00). Comparison of the "acceptable-unacceptable" proportions between clinical and radiographic examination methods using McNemar's Chi-square showed non-significant differences (p-values 0.317-1.00), and good level Kappa values (0.68-0.77). It is suggested that the new clinical examination method could be used as an alternative screening tool for alveolar bone graft assessment.

Comparison of the modified Huddart/Bodenham and GOSLON yardstick methods for assessing outcomes following primary surgery for unilateral cleft lip and palate.

OBJECTIVE: To test the measure of agreement between the modified Huddart/Bodenham scoring system and the GOSLON Yardstick for assessing the dental occlusions of patients with unilateral complete cleft lip and palate (UCLP) and to test the time taken for each assessment. MATERIAL AND METHOD: 60 sets of study models of 8-10-year-old UCLP patients who attended the Department of Orthodontics at the Faculty of Dentistry, Khon Kean University were evaluated. All subjects had undergone their cleft lip and palate repairs, but no alveolar bone grafts or any orthodontic treatment were done. The judgments of two trained examiners were used to place the modified Huddart/Bodenham score for each set of models into one of 5 categories corresponding to the GOSLON ratings to test for agreement between the two methods. The strength of agreement of ratings was analyzed by weighted kappa statistics. A paired t-test was carried out to compare the time taken in assessment with each index. RESULTS: There was good agreement between the two methods with a kappa value of 0.73. The GOSLON assessment took significantly less time than the modified Huddart/Bodenham assessment. CONCLUSION: The modified Huddart/Bodenham scoring system can be used as an alternative to the more commonly used GOSLON Yardstick for diagnostic purposes. Although the numerical scoring system takes more time, it provides more information about the sites of occlusal discrepancy than does the GOSLON Yardstick.