Prevalence of burnout among physiotherapists: a systematic review and meta-analysis.

BACKGROUND: Work-related burnout is a significant concern amongst healthcare professionals, including physiotherapists. It can negatively impact on both staff well-being and the quality of care delivered to patients. OBJECTIVES: To estimate the prevalence of burnout among physiotherapists. DATA SOURCES: PubMed, CINAHL, Web of Science, Embase, Scopus and PsycINFO, from inception to February 1st, 2022. STUDY SELECTION OR ELIGIBILITY CRITERIA: Studies reporting burnout prevalence among physiotherapists. DATA EXTRACTION AND DATA SYNTHESIS: Prevalence of burnout. Sub-analyses were performed grouping studies based on countries where surveys were conducted, classified as developed or developing countries. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale. RESULTS: 32 studies were included in the systematic review and 31 in the meta-analysis, enrolling a total of 5984 physiotherapists from 17 countries. Pooled prevalence (95% confidence interval) of burnout was 8% (4-15). Prevalence figures for Maslach Burnout Inventory dimensions were: (i) emotional exhaustion, 27% (21-34) (ii) depersonalization, 23% (15-32) (iii) low personal accomplishment, 25% (15-40). Both overall and single components prevalence was higher, although not significantly, in studies from developing than in developed countries. LIMITATIONS: Tools used to assess burnout and cut-off scores chosen to identify the burnout prevalence differed across studies. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: Prevalence of burnout reported by physiotherapists appears high worldwide, in particular in developing countries, and compares with that reported by nurses and physicians. Substantial heterogeneity in the prevalence of burnout, in its definition and assessment methods across studies, and limited quality of most studies precludes drawing definitive conclusions. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42022307876 CONTRIBUTION OF THE PAPER.

Spontaneous Mandibular Dentoalveolar Changes after Rapid Maxillary Expansion (RME), Slow Maxillary Expansion (SME), and Leaf Expander-A Systematic Review.

BACKGROUND: This systematic review aims to analyze the spontaneous dentoalveolar changes in the mandibular arch after maxillary expansion in growing patients obtained with different expansion protocols: Rapid Maxillary Expansion (RME), Slow Maxillary Expansion (SME), and Leaf Expander. METHODS: The study adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Eligibility criteria were established in the PICO format, involving patients who underwent slow, rapid, or leaf maxillary expansion during the mixed or early permanent dentitions. A comprehensive search of electronic databases and manual searches was conducted up to December 2023. The outcome measures included inter-mandibular first permanent molar width, inter-deciduous molar and canine width, arch perimeter, and arch length; both short- and long-term results were considered. The articles that met the inclusion criteria were included in this systematic review and were qualitatively evaluated using a methodological quality scoring system with a 13-point scale. To assess the inter-examiner agreement concerning the article selection and the qualitative assessment of the included studies, Kappa statistics were computed. RESULTS: A total of 1184 articles were identified through electronic and manual searches. After the removal of duplicates and the initial examination of the titles and abstracts, 57 articles were considered for the full text analysis, and according to the eligibility and exclusion criteria, 22 studies were finally selected, composed of 8 randomized controlled trials (RCTs) and 14 retrospective/case-control studies. The qualitative assessment of the included studies showed the following scores: 6 papers have high research quality, 5 have moderate quality, and 11 have low quality. SME demonstrated negligible mandibular changes, with less than 1 mm variation on average (range 0.46-2.00 mm) in the selected parameters and relapses observed in the long term. RME induced more significant increases, particularly in intermolar width greater than 1 mm, which ranged between 0.93 and 3.3 mm, and good stability over the long term. Leaf Expander exhibited promising short-term lower intermolar width increases greater than 1 mm and ranged from 0.5 to 1.69 mm, but long-term stability was not thoroughly evaluated. CONCLUSIONS: SME results in negligible short- and long-term effects, while RME, especially with Haas-type appliances, exhibits significant intermolar width increases that remain stable over the years. Leaf Expander shows short-term lower intermolar width increases, requiring further investigation into long-term stability.

Psychometric properties of the Parkinson's disease Questionnaire-39 and its short form Parkinson's disease Questionnaire-8: A systematic review and meta-analysis.

Parkinson's disease (PD) affects Quality of Life (QoL), since it is responsible for cognitive impairment, non-motor, and motor symptoms. Outcome measures are fundamental for evaluating treatment's effect on QoL over time. This systematic review aimed to identify the psychometric properties of PDQ-39 and PDQ-8 in the different populations in which they were validated. The electronic databases systematically searched are MEDLINE (via PubMed), CINAHL, SCOPUS, and Web of Science; the research was conducted in July 2023. The psychometric properties considered were those of the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. Risk of bias was assessed using the COSMIN checklist. The search identified 1306 articles. 398 duplicates were eliminated; 908 articles were analyzed reading title and abstract; 799 were finally excluded because used PDQ-39 and PDQ-8 as outcome measures or were not dealing with psychometric properties; 66 articles were excluded after reading the full text. 43 articles were included in the review; meta-analysis showed all the Cronbach's alpha values were statistically significant for all the subscales of PDQ-39 and PDQ-8. PDQ-39 demonstrated to be a specific HRQoL questionnaire that is correlated with generic HRQoL questionnaires, in fact in many studies included in the review, correlations with SF-36 were found. In the last studies about psychometric properties of PDQ-8 emerged that it is a practical and informative instrument that can be easily used in clinical settings, especially in busy ones, but also in large-scale studies in which a brief instrument would be preferred.

Minimal Clinically Important Difference of the Disabilities of the Arm, Shoulder and Hand (DASH) and the Shortened Version of the DASH (QuickDASH) in People With Musculoskeletal Disorders: A Systematic Review and Meta-Analysis.

OBJECTIVE: The objective of this study was to perform a meta-analysis of the minimal clinically important difference (MCID) of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and its shortened version (ie, the QuickDASH). METHODS: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, Cochrane Library, and Scopus were searched up to July 2022. Studies on people with upper limb musculoskeletal disorders that calculated the MCID by anchor-based methods were included. Descriptive and quantitative synthesis was used for the MCID and the minimal detectable change with 90% confidence (MDC90). Fixed-effects models and random-effect models were used for the meta-analysis. I2 statistics was computed to assess heterogeneity. The methodological quality of studies was assessed with the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist for measurement error and an adaptation of the checklist for the studies on MCID proposed by Bohannon and Glenney. RESULTS: Twelve studies (1677 patients) were included, producing 17 MCID estimates ranging from 8.3 to 18.0 DASH points and 8.0 to 18.1 QuickDASH points. The pooled MCIDs were 11.00 DASH points (95% CI = 8.59-13.41; I2 = 0%) and 11.97 QuickDASH points (95% CI = 9.60-14.33; I2 = 0%). The pooled MDC90s were 9.04 DASH points (95% CI = 6.46-11.62; I2 = 0%) and 9.03 QuickDASH points (95% CI = 6.36-11.71; I2 = 18%). Great methodological heterogeneity in the calculation of the MCID was identified among the primary studies. CONCLUSION: Reasonable MCID ranges of 12 to 14 DASH points and 12 to 15 QuickDASH points were established. The lower boundaries represent the first available measure above the pooled MDC90, and the upper limits represent the upper 95% CI of the pooled MCID. IMPACT: Reasonable ranges for the MCID of 12 to 14 DASH points and 12 to 15 QuickDASH points were proposed. The lower boundaries represent the first available measure above the pooled MDC90, and the upper limits represent the upper 95% CI of the pooled MCID. Information regarding the interpretability of the 2 questionnaires was derived from very different methodologies, making it difficult to identify reliable thresholds. Now clinicians and researchers can rely on more credible data. The proposed MCIDs should be used to assess people with musculoskeletal disorders. Heterogeneity was found related particularly to the anchor levels used in the primary studies. To promote comparability of MCID values, shared rules defining the most appropriate types of anchoring will be needed in the near future.

Probabilistic graphical modelling of early childhood caries development.

In order to develop a statistical model for complex interactions among factors affecting early childhood caries development (ECC), 234 children from the "XXXX oral growth longitudinal study" were analysed at ages 3, 4 and 5. A questionnaire for children's parents (clinical history, nutritional and oral hygiene habits) and clinical oral examinations were recorded each year. The probabilistic dependence structure on the most significant factors was modelled with an Undirected Graphical Model (UGM or Markov random fields) which provides a probabilistic reasoning approach for the establishment of multi-way associations. The best fitting UGM was estimated through the maximum likelihood principle and two-way factor associations were verified through Fisher's exact statistical hypothesis tests for count data. The effect of sugar intake on caries incidence is mediated by oral hygiene; for caries incidence, oral hygiene quality is more relevant than toothbrushing time; the effect of pacifier on caries incidence is statistically significant only when considered in combination with breastfeeding time. Among behavioural ECC risk factors, the quality of oral hygiene, and not the toothbrushing frequency, is a primary factor that modulates the sugar intake in his primary role of the ECC developer. School-based oral health programs for ECC prevention should be improved with supervised toothbrushing program. UGM analysis could improve the school-based oral health programs with more effective and efficient prevention strategies based on the hierarchical interactions among the ECC risk factors. Oral hygiene plays a pivotal role in early childhood caries and can modulate positively or negatively their development. Supervised toothbrushing is a crucial intervention to be included in the daily educational and clinical practice and in the school-based oral health promotion programs. Trial registration: Clinical trial registration number: NCT02798809.

Comparison of the skeletal, dentoalveolar, and periodontal changes after Ni-Ti leaf spring expander and rapid maxillary expansion: a three-dimensional CBCT based evaluation.

BACKGROUND: The aim of the present study was twofold:(1) three-dimensionally evaluate the quantitative skeletal and dentoalveolar changes after Ni-Ti leaf spring expander (leaf expander) and rapid maxillary expansion (RME) in mixed dentition patients;(2) analyze the modifications of the buccal alveolar bone plate of the maxillary first permanent molars. METHODS: Patients who underwent CBCT scans before and after maxillary expansion were randomly selected from the records archived at the Department of Biomedical Surgical and Dental Sciences, University of Milan, Italy. Inclusion criteria were the following: no systemic disease or syndromes; maxillary transverse deficiencies (difference between the upper intermolar width and the lower intermolar width of at least 3 mm and/or clinical need based on radiographic evaluation), early mixed dentition with ages between 7 to 10 years old; cervical vertebra maturation stage (CVMS) 1 or 2; no pathologic periodontal status; skeletal class I or II; maxillary expander cemented on the upper second deciduous molars. Exclusion criteria were the following: patients with pubertal or post-pubertal stage of development (CVMS 3-6); late deciduous or late mixed dentition, impossibility to use the second primary molar as anchorage; skeletal class III malocclusion; craniofacial syndromes; patients unable to be followed during the treatment period. Twenty-three patients treated with Leaf Expander, 11 males (mean age 7.8 ± 0.6 years) and 12 females (mean age 8.1 ± 0.8 years), met the inclusion criteria and constituted the case group. Twenty-four (control group) treated with conventional RME, 12 males (mean age 8.4 ± 0.9 years) and 12 females (mean age 8.1 ± 0.7 years). The paired-sample T test was used for intra-group comparison to evaluate the difference between before (T1) and after (T2) maxillary expansion. Independent sample t-test was computed to perform between groups comparison of the skeletal, dentoalveolar, and periodontal changes. RESULTS: The Leaf Expander and RME group showed a significant increase between T1 and T2 for most of the skeletal and dentoalveolar variables. Concerning the skeletal variables only the RME demonstrated a significant increase at the level of the posterior nasal (PNW) and apical base width (PABW) and maxillary mid-alveolar width (MMW). Despite this, when compare with the Leaf Expander, the RME group exhibited a statistically larger width increase for only two skeletal parameters: PNW (p = 0.03) and MMW (p = 0.02). No significant changes at the periodontal level were found in either group. CONCLUSIONS: According to the current research, the authors confirm the effectiveness of the Leaf Expander and RME to produce similar skeletal and dentoalveolar effects in mixed dentition subjects. Moreover, the devices anchored to deciduous teeth did not reduce the thickness and height of the buccal bone at the level of the maxillary permanent first molars in either of the two groups.

Evaluation of Enamel Surfaces after Different Techniques of Interproximal Enamel Reduction.

According to the literature, interproximal enamel reduction (IER) has become a consolidated technique used in orthodontic treatments to gain space in particular situations such as dental crowding, non-extractive therapies, tooth-size discrepancies, and prevention of dental relapse. There are different methods to realize stripping, and enamel surfaces resulting after this procedure can be analyzed with SEM. The aim of this study was to analyze how different devices of IER leave the surface of the teeth. One hundred and sixty freshly extracted, intact human lower incisors were included in the study, fixed in a plaster support, and then processed with four different techniques of enamel reduction and finishing. Then, they were divided randomly into eight groups (A1-A2, B1-B2, C1-C2, D, and E), each containing twenty teeth. The A, B, and C groups were divided into two subgroups and then all the teeth were observed at SEM. Each digital image acquired by SEM showed that there were streaks on the surfaces, due to the cutter used. The results of this study showed that only group C2 (tungsten carbide bur followed by twelve steps of medium-fine-ultrafine 3M Soft Lex disks) has a few line, which is very similar to group E (untreated group), while the other groups have a lot of lines and show a rougher final surface.

Implant Site Changes in Three Different Clinical Approaches: Orthodontic Extrusion, Regenerative Surgery and Spontaneous Healing after Extraction: A Systematic Review.

Both surgical and non-surgical techniques are employed for implant site development. However, the efficacy of these methods has not been thoroughly evaluated and compared. This systematic review aims to compare the biologic, functional and esthetic outcomes of three different approaches before implant placement in both the maxillary and mandibular arches: orthodontic extrusion, regenerative surgery and spontaneous healing after extraction. The systematic research of articles was conducted up to January 2020 in Medline, Scopus and the Cochrane Library databases. Studies were selected in a three-stage process according to the title, the abstract and the inclusion criteria. The methodological quality and the risk of bias of the included studies were evaluated using ROBINS-I tools for non-randomized studies, Rob 2.0 for RCT. Quality evaluation of case reports was performed using CARE guidelines. Through the digital search, 1607 articles were identified, and 25 of them were included in the systematic review. The qualitative evaluation showed a good methodological quality for RCT, sufficient for non-randomized studies and poor for case reports. Based on the available results, both orthodontic extrusion and regenerative surgery allowed the development of the implant site with satisfying esthetic and functional outcomes. Studies about the spontaneous healing of the extraction socket showed resorption of the edentulous ridge, which complicated the implant insertion. No study referred to failures or severe complications. Most of the studies reported only qualitative results. The present systematic review demonstrated that there is a substantial lack of data and evidence to determine which of the presented methods is better for developing a future implant site. Both surgical and non-surgical procedures appear effective in the regeneration of hard tissue, whereas not all the techniques can improve soft tissue volume, too. The orthodontic technique simultaneously enhances both hard and soft tissue.

A CBCT based analysis of the correlation between volumetric morphology of the frontal sinuses and the facial growth pattern in caucasian subjects. A cross-sectional study.

BACKGROUND: The aim of this study was to evaluate the relationship between frontal sinus shape and facial growth pattern. METHODS: The three-dimensional examination was carried out by means of 80 CBCT scans selected from a sample of 1247 records of patients treated, for different reason, at the Department of Biomedical Surgical and Dental Sciences at University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico Milan. The sample (age ranges between 12 and 40 years) was divided according to gender and age in four groups (12-17, 18-20, 21-30, 31-40). Left and right frontal sinus volume (VOL), surface (SUP) and linear maximum width (XMAX), depth (ZMAX) and height (YMAX) were calculated using Mimics Research 17.0 (Materialise N.V., Leuven, Belgium). Cephalometric analysis has been performed for all subjects to categorize the patients depending on their facial growth pattern. Univariate and multivariate regression analysis were performed to investigate any association of frontal sinuses measurements (height, width, depth, volume and surface) and cephalometric variables. P value < 0.05 was considered statistically significant. RESULTS: A total of 160 frontal sinuses were measures in 80 patients: 40 men and 40 women, average age of 23.5 ±14.6. Globally the frontal sinuses had the following average dimensions: volumes of 9055.8 ± 6505 mm3 and surfaces of 3820.3 ± 2125 mm2. The statistical analysis showed that frontal sinus volume was statistically significant (p=0.003) greater for male (11,425 mm3) than female (6597.5 mm3). Similarly, the surface showed to be greater in men than in women (p=0.005). No correlation between age and frontal sinuses characteristics has been found. A statistically significant (p<0.05) increase of frontal sinus depth, surface and volume was correlated with SNB angle. In addition, frontal sinus volume increased in subjects with greater anterior skeletal dimension values and with a superior length of the cranial base. Furthermore, a decrease of ANB has been found related to an increase in frontal sinus volume (p=0.04). CONCLUSIONS: The present study showed a correlation between frontal sinuses dimensions and craniofacial aspects, despite the inter-individual variability of their morphology. The results suggested that young adults in whom the frontal sinuses have reached their maximum size, while vertical growth continues, a larger frontal sinus may be associated with future vertical growth.

Orthodontic treatment for posterior crossbites.

BACKGROUND: A posterior crossbite occurs when the top back teeth bite inside the bottom back teeth. The prevalence of posterior crossbite is around 4% and 17% of children and adolescents in Europe and America, respectively. Several treatments have been recommended to correct this problem, which is related to such dental issues as tooth attrition, abnormal development of the jaws, joint problems, and imbalanced facial appearance. Treatments involve expanding the upper jaw with an orthodontic appliance, which can be fixed (e.g. quad-helix) or removable (e.g. expansion plate). This is the third update of a Cochrane review first published in 2001. OBJECTIVES: To assess the effects of different orthodontic treatments for posterior crossbites. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched four bibliographic databases up to 8 April 2021 and used additional search methods to identify published, unpublished and ongoing studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) of orthodontic treatment for posterior crossbites in children and adults. DATA COLLECTION AND ANALYSIS: Two review authors, independently and in duplicate, screened the results of the electronic searches, extracted data, and assessed the risk of bias of the included studies. A third review author participated to resolve disagreements. We used risk ratios (RR) and 95% confidence intervals (CIs) to summarise dichotomous data (event), unless there were zero values in trial arms, in which case we used odds ratios (ORs). We used mean differences (MD) with 95% CIs to summarise continuous data. We performed meta-analyses using fixed-effect models. We used the GRADE approach to assess the certainty of the evidence for the main outcomes. MAIN RESULTS: We included 31 studies that randomised approximately 1410 participants. Eight studies were at low risk of bias, 15 were at high risk of bias, and eight were unclear. Intervention versus observation For children (age 7 to 11 years), quad-helix was beneficial for posterior crossbite correction compared to observation (OR 50.59, 95% CI 26.77 to 95.60; 3 studies, 149 participants; high-certainty evidence) and resulted in higher final inter-molar distances (MD 4.71 mm, 95% CI 4.31 to 5.10; 3 studies, 146 participants; moderate-certainty evidence). For children, expansion plates were also beneficial for posterior crossbite correction compared to observation (OR 25.26, 95% CI 13.08 to 48.77; 3 studies, 148 participants; high-certainty evidence) and resulted in higher final inter-molar distances (MD 3.30 mm, 95% CI 2.88 to 3.73; 3 studies, 145 participants, 3 studies; moderate-certainty evidence). In addition, expansion plates resulted in higher inter-canine distances (MD 2.59 mm, 95% CI 2.18 to 3.01; 3 studies, 145 participants; moderate-certainty evidence). The use of Hyrax is probably effective for correcting posterior crossbite compared to observation (OR 48.02, 95% CI 21.58 to 106.87; 93 participants, 3 studies; moderate-certainty evidence). Two of the studies focused on adolescents (age 12 to 16 years) and found that Hyrax increased the inter-molar distance compared with observation (MD 5.80, 95% CI 5.15 to 6.45; 2 studies, 72 participants; moderate-certainty evidence). Intervention A versus intervention B When comparing quad-helix with expansion plates in children, quad-helix was more effective for posterior crossbite correction (RR 1.29, 95% CI 1.13 to 1.46; 3 studies, 151 participants; moderate-certainty evidence), final inter-molar distance (MD 1.48 mm, 95% CI 0.91 mm to 2.04 mm; 3 studies, 151 participants; high-certainty evidence), inter-canine distance (0.59 mm higher (95% CI 0.09 mm  to 1.08 mm; 3 studies, 151 participants; low-certainty evidence) and length of treatment (MD -3.15 months, 95% CI -4.04 to -2.25; 3 studies, 148 participants; moderate-certainty evidence). There was no evidence of a difference between Hyrax and Haas for posterior crossbite correction (RR 1.05, 95% CI 0.94 to 1.18; 3 studies, 83 participants; moderate-certainty evidence) or inter-molar distance (MD -0.15 mm, 95% CI -0.86 mm to 0.56 mm; 2 studies of adolescents, 46 participants; moderate-certainty evidence). There was no evidence of a difference between Hyrax and tooth-bone-borne expansion for crossbite correction (RR 1.02, 95% CI 0.92 to 1.12; I² = 0%; 3 studies, 120 participants; low-certainty evidence) or inter-molar distance (MD -0.66 mm, 95% CI -1.36 mm to 0.04 mm; I² = 0%; 2 studies, 65 participants; low-certainty evidence).  There was no evidence of a difference between Hyrax with bone-borne expansion for posterior crossbite correction (RR 1.00, 95% CI 0.94 to 1.07; I² = 0%; 2 studies of adolescents, 81 participants; low-certainty evidence) or inter-molar distance (MD -0.14 mm, 95% CI -0.85 mm to 0.57 mm; I² = 0%; 2 studies, 81 participants; low-certainty evidence).  AUTHORS' CONCLUSIONS: For children in the early mixed dentition stage (age 7 to 11 years old), quad-helix and expansion plates are more beneficial than no treatment for correcting posterior crossbites. Expansion plates also increase the inter-canine distance. Quad-helix is more effective than expansion plates for correcting posterior crossbite and increasing inter-molar distance. Treatment duration is shorter with quad-helix than expansion plates. For adolescents in permanent dentition (age 12 to 16 years old), Hyrax and Haas are similar for posterior crossbite correction and increasing the inter-molar distance. The remaining evidence was insufficient to draw any robust conclusions for the efficacy of posterior crossbite correction.

A Comparative Evaluation of Inertial Sensors for Gait and Jump Analysis.

Gait and jump anomalies are often used as indicators to identify the presence and state of disorders that involve motor symptoms. Physical tests are often performed in specialized laboratories, which offer reliable and accurate results, but require long and costly analyses performed by specialized personnel. The use of inertial sensors for gait and jump evaluation offers an easy-to-use low-cost alternative, potentially applicable by the patients themselves at home. In this paper, we compared three inertial measurement units that are available on the market by means of well-known standardized tests for the evaluation of gait and jump behavior. The aim of the study was to highlight the strengths and weaknesses of each of the tested sensors, considered in different tests, by comparing data collected on two healthy subjects. Data were processed to identify the phases of the movement and the possible inaccuracies of each sensor. The analysis showed that some of the considered inertial units could be reliably used to identify the gait and jump phases and could be employed to detect anomalies, potentially suggesting the presence of disorders.

Barriers to evidence-based practice implementation in physiotherapy: a systematic review and meta-analysis.

BACKGROUND: To review and meta-analyse the evidence about the prevalence of barriers to evidence-based practice (EBP) reported in physiotherapy. METHODS: Two independent investigators conducted an extensive electronic search in EMBASE, PubMed, Scopus, Web of Science and CINAHL databases from their inception to July 2020 and included the retrieved articles if they investigated barriers to EBP among physiotherapy professionals. Subsequently, they extracted data and assessed the methodological quality using a scale described in a similar previous study. The outcome for meta-analysis was frequency of each reported barrier. Sub-analyses were performed grouping studies based on countries where surveys were performed, classified as either developed or developing countries. RESULTS: Twenty-nine articles were included in the systematic reviews and meta-analysis. Risk of bias assessment of included studies showed a median score: 4 points (interquartile range: 3-4). The findings of meta-analysis revealed that lack of time was the most frequently reported barrier (53.0% [95% confidence interval, 95%CI, 44.0-62.0]), followed by language (36.0% [95%CI 16.0-62.0]), lack of access (34.0% [95%CI 23.0.27]) and lack of statistical skills (31.0% [95%CI 20.0-44.0]). Lack of skills and lack of generalizability were declared as barriers by 27.0% [95%CI 18.0-38.0] and 23.0% [95%CI 15.0-33.0] of responders, respectively. Lack of support and lack of interest are less frequent, with 16.0% [95%CI 11.0-24.0] and 9.0% [95%CI 6.0-15.0] of responses, respectively. Barriers reported in investigations performed in developed countries were less frequent when compared to those performed in developing countries. CONCLUSION: Organizational issues and methodological skills seem key issues to allow the implementation of EBP, suggesting the need to adopt or enhance organizational and training strategies to facilitate the implementation of the EBP. Quantitative synthesis showed high heterogeneity for all analyses, and therefore, pooled data should be interpreted with caution.

Measurement properties of the Gross Motor Function Classification System, Gross Motor Function Classification System-Expanded & Revised, Manual Ability Classification System, and Communication Function Classification System in cerebral palsy: a systematic review with meta-analysis.

AIM: To systematically review and meta-analyse the measurement properties of the Gross Motor Function Classification System (GMFCS), Gross Motor Function Classification System-Expanded & Revised (GMFCS-E&R), Manual Ability Classification System (MACS), and Communication Function Classification System (CFCS) in children with cerebral palsy (CP). METHOD: Six databases were searched. Articles on the measurement properties of the GMFCS, GMFCS-E&R, MACS, and CFCS administered to children with CP were included. Quality was assessed by means of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist. The level and grading of evidence were defined for each measurement property. RESULTS: Forty-four articles were included in the systematic review and 37 articles were included in the meta-analysis. The level (grading) of evidence was strong (positive) for reliability and construct validity. Content validity displayed an unknown level of evidence for the GMFCS, limited evidence (positive) for the MACS, and moderate evidence (positive) for the CFCS. There was moderate (positive) evidence for measurement error in the GMFCS and MACS. The level of evidence for responsiveness was unknown. No studies investigated cross-cultural validity. INTERPRETATION: These instruments can be used by health care professionals and caregivers to quantify the constructs needed to measure ability in children with CP. Current high-quality evidence supports the use of these tools to classify ability in children with CP. Adopting the COSMIN guidelines, content, and cross-cultural validity should be investigated further. What this paper adds Strong evidence supports the reliability and construct validity of the GMFCS, GMFCS-E&R, MACS, and CFCS as functional classification systems in children with cerebral palsy. The GMFCS, GMFCS-E&R, MACS, and CFCS can be used by both health care professionals and caregivers. The GMFCS, GMFCS-E&R, MACS, and CFCS should not be used to detect change.

Correlation between facial growth patterns and cortical bone thickness assessed with cone-beam computed tomography in young adult untreated patients.

BACKGROUND: The vertical facial growth pattern is one of the most important issue in the orthodontic diagnosis and treatment. Previous studies investigated the association between interdental bone thickness and facial divergence using mainly bidimensional analysis. When two-dimensional dental radiographic views are not sufficient for diagnosis and measurements, cone-beam computed tomography (CBCT) images should be used to assess the alveolar bone structure three-dimensionally and with high accuracy and reliability.The aim of the present study was to evaluate the correlation between alveolar bone thickness and facial divergence in young adults untreated patients using a three-dimensional method analysis with CBCT images. METHODS: Records of 30 untreated patients (mean age 16 ± 2 years) with Angle Class I and mild to moderate crowding were analyzed. Subjects were classified as hypodivergent (<39˚), normodivergent (41 ± 2˚), and hyperdivergent (>43°). according to the inter-maxillary angle between the sagittal maxillary plane (ANS-PNS) and the mandibular plane (GN-ME). The alveolar bone thickness measurements were taken for the buccal and palatal/lingual surfaces of maxillary and mandibular anterior teeth. Axial-guided navigation (AGN) was used to locate all landmarks using a specific software (Horos 3.0). RESULTS: The statistical analysis showed a significant difference between the hypodivergent and hyperdivergent group regarding buccal bone height (P = 0.005), buccal apical bone thickness (P = 0.003) and palatal mid-root bone thickness (P = 0.006). Moreover, buccal bone height (P = 0.006) was found to be statistically significant different in normodivergent compared with hypodivergent individuals. CONCLUSIONS: Facial types were found to be correlated with alveolar bone thickness. The hyperdivergent subjects presented thinner alveolus bone in the anterior maxilla and at almost all sites in the mandible. Clinicians should be aware of the possibility of thin cortical bone plates in hyperdivergent patients, reducing antero-posterior movements to avoid fenestration and dehiscence.

Maxillary dento-skeletal outcomes after orthopedic forward (class III) and backward (class II) traction in growing subjects.

BACKGROUND: This retrospective study investigated the treatment effects produced by two orthopedic appliances, an extraoral orthopedic traction on Stephenson plate (SP) in skeletal Class II malocclusion and Delaire Facial Mask (FM) in skeletal Class III malocclusion. METHODS: FM Group comprised 25 patients (13 males; 12 females, mean age 9.3 years, CS 1-2) undergoing Delaire Facial Mask therapy (mean treatment duration 1.5 years ± 1.2, 700-800 gr per side). SP Group comprised 24 patients (9 males; 15 females, mean age 10.5 years ± 1.9, CS 1-3) treated with extraoral orthopedic traction on Stephenson plate (mean treatment duration 1.6 years ± 0.8, 700-900 gr per side). For all subjects lateral cephalograms before (T0) and after (T1) therapy were obtained and traced. Descriptive statistics, t-test and Shapiro-Wilks test were calculated for each variable. RESULTS: A mesial movement of the maxillary bone of 2.4 mm in the FM group and a distal movement in the PS group (0.4 mm) was found. SNA° was reduced 1.4° after SP and increased 0.7° after FM. The overjet decreased by 4 mm after SP, while it grew after FM by 2.4 mm, as well as molars relationships (4.5 vs. 0.8 mm). CONCLUSIONS: Facemask induced greater skeletal movements than extraoral traction on Stephenson plate. PS produced a limited downward movement of the whole maxilla together with notable incisors and molars back corrections. Based on our results, it could be speculated that orthopedic mesial traction of maxillary bone may result easier than the distal movement.

Buccal Bone Changes Around First Permanent Molars and Second Primary Molars after Maxillary Expansion with a Low Compliance Ni-Ti Leaf Spring Expander.

Background: Vestibular bone thickness changes and dento-alveolar buccal tipping of second primary molars and of first molars after maxillary expansion performed with a slow maxillary expansion protocol was investigated. Methods: Twenty patients (mean age 7.3 ± 0.9 years old; 9 male and 11 female) were treated according to the Leaf Expander protocol. Buccal alveolar bone thickness (BT), buccal alveolar bone height (BH), inter-dental angle (TIP), and inter-molar width (IW) regarding first molars and second primary molars were calculated before and after expansion on cone beam computed tomography (CBCT) images. Descriptive statistics and paired t-tests were used to assess changes between the pre-treatment and post-treatment measurements. Results: Bone thickness vestibular to second primary molars and intermolar width of both teeth were the only variables that showed statistically significant changes. Conclusions: It appears that buccal bone thickness vestibular to first molars was not significantly reduced after maxillary expansion with the Leaf Expander. The clinical use of a slow maxillary expander with Ni-Ti springs appears efficient and safe in in the correction of maxillary hypoplasia during mixed dentition.

Palatal changes in crossbite patients treated with rapid maxillary expansion vs untreated ones: A geometric morphometric study.

OBJECTIVE: The present study aimed to analyse palatal changes due to rapid maxillary expansion (RME) by using modern geometric morphometric analysis (GMA) on 3D models. SETTINGS AND SAMPLE POPULATION: Forty children with posterior crossbite and maxillary deficiency were selected for this study. Twenty children were treated with RME (mean age 7.4 ± 0.8 years), whereas 20 children were not treated (mean age 7.2 ± 1.1 years). MATERIALS AND METHODS: In the treated group, RME screw was activated until overcorrection was achieved and the RME appliance remained in place for 11 months. Digital dental casts were recorded before treatment and 1 year after the end of active treatment. GMA was performed to compare shape and dimensional variations among groups (between-group principal component analysis). RESULTS: All children in the treated group achieved crossbite correction. None of the control group children achieved crossbite self-correction. No significant shape and dimensional changes were noted in the control group after 1 year. On the other hand, significant shape and dimensional changes were noted in the treated group after 1 year (P < .05). Most of the shape changes in the treated group were similar but more pronounced compared to those observed in the control group. All major changes in palatal morphology occurred on the lateral sides of the palatal vault (widening) and at the height (shortening). Some shape changes were observed in the treated group alone. CONCLUSIONS: Application of GMA to evaluate the effects of RME in crossbite patients revealed significant changes in palatal morphology compared with the absence of changes in the control group.

Volumetric Changes in the Upper Airways after Rapid and Slow Maxillary Expansion in Growing Patients: A Case-Control Study.

The aim is to evaluate changes in the volume of the upper airways before and after slow maxillary expansion (SME) obtained with the flexible properties of a nickel titanium leaf spring and rapid maxillary expansion (RME) with a conventional Hyrax appliance in growing patients. The records of 1200 orthodontic patients undergoing maxillary expansion from 2018 to 2019 were analyzed; among these pre and post treatment CBCT scans of 22 patients (mean age 8.2 ± 0.6 years old) treated by SME were compared with those obtained from 22 patients (mean age 8.1 ± 0.7 years old) treated by RME banded on the second primary molars. The following inclusion criteria were used: Maxillary transverse constriction, good general health, and no previous orthodontic treatment. Volumes of nasal cavity (NCavV), nasopharynx (NsPxV), and right and left maxillary sinuses (MSV) were calculated with ITK-SNAP. Shapiro-Wilk test revealed a normal distribution of data in each group. Paired t-test was used for within-group comparisons and independent t-test for between-group comparisons. Statistically significant increases occurred in NCavV, NsPxV, and MSVs after treatment with both appliances. No statistically significant difference between the appliances occurred in NCavV, NsPxV, and MSVs. Method error was considered negligible (mean intra-operator and inter-operator intraclass correlation coefficient were 0.928 and 0.911, respectively). It appears that both appliances produce similar effects on the different segments of the upper airway tract.

Upper canine response to rapid maxillary expander anchored to deciduous vs. permanent molars.

PURPOSE: To understand whether two different designs of Haas-type rapid maxillary expander (H­RME) might have a different influence on canine eruption. PATIENTS AND METHODS: In all, 108 subjects seeking orthodontic treatment were selected and divided into two groups-H­RME with bands on the upper second deciduous molars (GrE), H­RME with bands on the upper first permanent molars (Gr6)-and were also compared to an historical untreated control group (CG) of 29 subjects. Panoramic x­rays (OPG) were performed before and after RME (T0-T1: 16 ± 7 months) and the upper canine angulation to the midline ("α" angle) was measured on both pre- and posttreatment OPG. RESULTS: A significant improvement of the canine position (decrease of the α angle) following RME in subjects with mixed dentition was reported in both treated groups, although the different design of the RME did not significantly affect canine angulation. Canine angulation in untreated subjects with transversal discrepancy did not improve significantly. CONCLUSION: Using RME in the early mixed dentition appears to be an effective procedure to increase the rate of eruption of maxillary canines, but the position of the bands on the upper second deciduous molars or on the upper first permanent molars and the significant different expansion of the upper dental arch at the canine level does not significantly influence the canine angulation following early treatment therapy.

Assessment of the Stability of the Palatal Rugae in a 3D-3D Superimposition Technique Following Slow Maxillary Expansion (SME).

The Palatal Rugae are considered a useful human identification marker for both orthodontists and forensic personnel. The principal aim of the present study was to evaluate the stability of palatal rugae with a 3D-3D superimposition procedure following Slow Maxillary Expansion (SME), in order to assess whether they kept their uniqueness and validity for human identification, even after a specific dental treatment. For this purpose, a sample of 27 digital dental models - belonging to growing patients (13 males and 14 females), aged between 8.5 and 15 years, who underwent SME therapy - was retrospectively studied and compared with a control group of 27 untreated subjects - (13 males and 14 females). Digital dental models were obtained pre-treatment and at device removal; both were processed by means of an intraoral scanner. A superimposition procedure was thus performed to reach the minimum point-to-point distance between two models of palatal rugae. Intra- and inter-observer differences were statistically analyzed by paired Wilcoxon test and Intra-class Correlation coefficient (ICC), showing values larger than 0.93. There was no difference in Root-Mean-Square (RMS) values between untreated control subjects and subjects treated with Leaf Expander (p = 0.062). A RMS value of 0.43 was the threshold to distinguish the pooled group ("Untreated" and "Leaf") from any mismatch. According to the obtained results, this study failed to reject the null hypothesis and presented no differences between the RMS values of the Test group and the RMS values of the untreated control group. This work highlighted the usefulness of 3D superimposition procedure for purposes of human identification, in subjects undergoing dental treatment. However, keeping in sight the forensic use of this technique as a helpful probation element in court, further studies should be performed to confirm these findings.