Wednesday, January 30, 2013

Communication in Orthodontic Treatment Planning: Bioethical and informed consent issues

Communication in Orthodontic Treatment Planning: Bioethical and informed consent issues

Resident: Todd Bushman
Author: James L. Ackerman DDS; William R. Proffit DDS
Journal: The Angle Orthodontist Vol 65 No.4 1995
Purpose: The main purpose of this article is to talk about the frame of reference of ortho treatment from the patients perspective and how that can differ from the orthodontist.  It gives recommendations for treatment and considerations regarding ethics. 
  • Patients are now much more involved in theoir trwetment than they have been in the past.  Before the practicioner would recommend a treatment and it would be implimented without much input from the patient as co-decision makers. 
  • Patients should beknow all treatment options with their risks and benefits so they can make an informed decision based on what is best for them. 
  • The dentist and the patient may not see eye to eye on what might be considered a good outcome is.  The patient may want an acceptable outcome with the least amount of treatment time
  • The dentist can sometimes be hesitant to suggest a very aggressive treatment plan because they think the patient may reject treatment entirely.  
  • Software and photo simulations are effective in helping patients decide on what treatment option they will choose.
  • Parents can not always be relied upon to choose the best treatment option.
  • Sometimes too much information can be given with expectations set too high.  It is important to give realistic goals and if optimal outcomes are not predictable this should be dicussed and documented. 
  • Treatment conference should consist of 3 phases-
    • 1 Present findings and a prioritized problem list. 
    • 2 Risk/Benefit analysis and treatment alternatives
    • 3 Discussion of expectations and deciding on a plan 
Assessment: This article brings up some interesting points and gives some good examples of why it is important to talk to your patients and make sure they know very well what to expect.  They need to be heavily involved in the process while being very well informed.  This will increase the satisfaction level of the patients as well as decrease the liability of the dentist.  

Predicting functional appliance treatment outcome in Class II malocclusions-a review

Resident: Matthew Freitas
Author: Susi Barton, BDS
Journal: American Journal of Ortho and Dentofacial Orthopedics Vol 112, No. 3

-Functional appliances are either removable or fixed, and hold the mandible in a postured forward position with the idea of encouraging mandibular growth.
-Several functional appliances are available to treat Class II, but the results are variable and unpredictable.
-This has resulted in much controversy over their use.

-To review the factors that have been proposed as playing an important role in functional appliance treatment outcome.

1. Patient Compliance: Success with many functional appliances is dependent on patient compliance (especially removable appliances). One study monitored compliance found that most patients were were using the appliance 50% of the suggested time (7hrs a day vs the recommended 14hrs).

2. Facial Growth: Many believe that functional appliance therapy should be coordinated during the time of rapid facial growth for the most benefit (girls: 10.5-14 and boys: 12.5-16). However, the authors point out that it's very difficult to determine this maximum growth period.

3. Overjet: One study by Dickson found that patients who had smaller overjet, less than 7mm, showed the highest success rate over those with severe overjet of +11mm.

4. Incisor Angulation: There have been no investigations into the relationship of incisor angulation relative to the max and mand plane and treatment outcome.

5. Vertical Relationship: The overbite, maxillary-mandibular plane angle (MMPA) and the anterior facial height. Studies found that an openbite become more severe after treatment.

6. Saggital Relationship: The authors found no evidence supporting a favorable change in saggital relationship from functional appliances.

7. Dental Alignment: There is no evidence to support functional appliances having more benefit in Class II with crowding.

-There's a lack of evidence that strongly supports use of functional appliances for the mandibular arch to permanently correct class II malocclusions. It seems that most of the success is temporary posturing and Brennan always points out that it's impossible for us to grow mandibles (maxillary arch is different).
-The authors believe that functional appliances are unpredictable and should be limited to Class II malocclusions with:
1. mild overjet less than 11mm
2. deeper bite
3. active facial growth period
4. willingness to comply

Treatment Timing for Rapid Maxillary Expansion

Resident: Mackenzie Craik

Article: Treatment Timing for Rapid Maxillary Expansion

Authors: Baccetti, Franchi, Cameron, McNamara

Publication: Angle Orthodontist Vol. 71, Nov. 5, 2001.

Purpose: To evaluate the short-term and long-term treatment effects of rapid maxillary expansion in 2 groups of subjects treated with the Haas appliance.

Methods: The treatment group for this study was derived from the long-term records of patients who had undergone Haas-type Rapid Maxillary Expansion (RME).  The cephalometric radiographs analyzed were taken according to a standardized technique.  The patients originally were judged by the practitioner to have transverse maxillary deficiency as part of their overall orthodontic problem.  Treatment outcomes were evaluated before and after the peak in skeletal maturation, as assessed by the cervical vertebral maturation method, in a sample of 42 patients compared to a control sample of 20 patients.  These patients underwent Haas-type RME with 2 turns a day until the expansion screw reached 10.5 mm.  The Haas expander was then kept in the mouth as a retainer for an additional 65 days.  Pubertal peak can be identified using the Cervical Vertebral Maturation (CVM) method.  By comparing the inferior borders of the 2nd through 6th vertebrae one can determine proximity to the peak of pubertal growth.  There are six stages in the CVM method and the peak growth is considered to be between Class III and Class IV, at which point the inferior borders of vertabrae 2-4 will become concave instead of flat.

Results: The group treated before the pubertal peak showed significantly greater short-term increases in the width of the nasal cavities.  In the long-term, maxillary skeletal width, maxillary intermolar width, lateronasal width, and laterorbitale width were significantly greater in the early-treated group.  The late treated group exhibited significant increases in lateronasal width and in maxillary and mandibular intermolar widths.

Conclusions:  Patients treated before the pubertal peak exhibit significant and more effective long term changes at the skeletal level in both maxillary and circum-maxillary structures.  When RME treatment is performed after the pubertal growth spurt, maxillary adaptations to expansion therapy shift from the skeletal level to the dentoaleolar level.

Assessment: Dr. Brennan talked with us about this concept of inspecting the vertebrae to determine the peak of pubertal growth.  This CVM method is more reliable than evaluating the ossification of the Hamate bone in the wrist to identify the proper time to treat orthodontically.

Tuesday, January 29, 2013

Resorption of Incisors after Ectopic Eruption of Maxillary Canines: A CT Study

Sune Ericson DDS PhD; Juri Kurol DDS PhD

Resident: Sadler 

Angle Orthodontist Vol, 70 No.6 2000

Purpose: Analyze the frequency and factors associated with the resorption of maxillary incisors after ectopic eruption of canines

Methods:  107 children (39 boys and 68 girls) aged 9-15 were used as the study population.  Patients were evaluated with traditional radiographs and panoramics but also with CT scans.  Data was collected and analyzed

Key points:

  • 93% of ectopically erupting canines were in contact with the adjacent lateral with 19% being in contact with the central (transposed) 
  • Lateral incisors were slightly resorbed in 31% of cases, moderately in 9%, and severely with pulpal involvement in 60%.  Similar numbers were observed with centrals.
  • On a control side (no ectopic canine) 3 laterals were observed to have resorbed
  • There is a statistically significant correlation between ectopic canines and resorption of the adjacent incisor
  • No correlation between age or gender was found
  • Preemptive extraction of the primary canine has been shown to aid in correcting the eruption and should be the first step taken if ectopic eruption is suspected. 
Assesment:  This was a very dry article that essentially took alot of CT scans to demonstrate that resorption was associated with ectopic eruption.  I think its nice to know that as you need to make sure that parents are aware that more than likely, there will be some consequence for adjacent teeth when canines are ectopically erupting.  

The Use of the Lingual Arch in the Mixed Dentition to Resolve Incisor Crowding

Resident: Jeff Higbee
Article: The Use of the Lingual Arch in the Mixed Dentition to Resolve Incisor Crowding
Authors: Brennen, M.; Gianelly, A.
Journal: American Journal of Orthodontics and Dentofacial Orthopedics

To determine how often arch length preservation by means of a passive lingual arch can provide sufficient space to resolve incisor crowding during the transition for the mixed to the permanent dentition.

- Passive lingual arches were placed in 107 patients with a mixed dentition and had incisor crowding or early loss of deciduous canine. 
-  43 males n 64 females in the sample with an average age of 8.6 years.
- There were 2 time periods evaluated
T1: Mixed dentition, at least all permanent mandibular incisors and first molars were present as well as both primary second molars. 
T2: Early permanent dentition all permanent mandibular teeth mesial to the first molars were erupted, with at least 50% eruption of both second premolars.  In one instance, the second premolars were impacted. 
- All measurements were made with digital calipers and recorded to the nearest 0.01 mm.

- The lingual arch appliances used in the 107 patients were effective in maintaining arch length throughout the transition from the mixed to the permanent dentition.
 The arch length loss was only 0.4 mm and the leeway space was essentially preserved. 
- After the LLHA adequate space to resolve crowding was available in 60% of the patients with an average of 4.85mm of crowding at the beginning. 
- Because arch length preservation by a simple passive LLHA, along with other developmental changes in the transitional dentition, can provide adequate space to correct 4-5 mm of crowding in the majority of patients, the clinician has the opportunity to correct crowding as long as the arch length is preserved. 

This is a good article that Dr. Brennen has already talked to us about.  It is good info to have and a good simple way to correct lower incisor crowding.  First thought at 4-5 mm of incisor crowding might lead you to think ext/ortho but with maintenance of the leeway space using a passive LLHA,  crowding can be corrected. 

Dentoalveolar and skeletal changes associated with the pendulum appliance

Kyung-Hong Cal Kim

Dentoalveolar and skeletal changes associated with the pendulum appliance

Authors: Bussic TJ, McNamara JA

American Journal of Orthodontics and Dentofacial Orthopedics March 2000

To examine the dentoalveolar and skeletal effects of the pendulum appliance in Class II patients at varying stages of dental development and with varying facial patterns

Background Information:

Pendulum appliance
-2 hybrid appliances, the pendulum and pendex, that requires no patient compliance
-Overcorrection of the molars to Class III relationship, followed by stabilization for 6 to 10 weeks.
-Approximately 5mm of distal movement in a 3- to 4-month period of time

-Final sample: 56 females + 45 males from 13 practitioners
-Pre-treatment ceph (T1) + Post-treatment ceph (T2) upon removal of pendulum appliance
-Mean length of tx (T1 to T2) = 7 +/- 2 months
-Subgroups: +/- maxillary Es, +/- maxillary 7s, MPA relative to Frankfort Horizontal

-Space opening anterior to 6s = 76% distalization of 6s + 24% reciprocal anchorage loss of the maxillary 5s
-Maxillary centrals proclined slightly during tx, and 10 degree of distal tipping was observed in 6s during tx
-Increased facial height = upward tipping of occlusal plane, sight opening of mandibular plane
-No difference in the amount of distalization of 6s between pts w/ erupted 7s and those w/ unerupted 7s, but significant increases in lower anterior facial height and small increase in OB in pts w/ erupted 7s
-Increases in extrusion of 6s and lower anterior facial height and a decrease in OB noted in pts with permanent dentition anchorage (5s)
-For maximum maxillary first molar distalization with minimal increase in lower anterior facial height, pendulum appliance is to be used on patients with maxillary Es for anchorage and unerupted 7s.

Assessment of the Article:
It was a pretty self-explanatory article that compares and discusses effectiveness of pendulum appliances in correcting Class II malocclusion in patients with various dental ages.

Tooth anomalies associated with failure of eruption of first and second permanent molars

Resident: Elliot Chiu
Title: Tooth anomalies associated with failure of eruption of first and second permanent molars
Journal: American Journal of Orthodontics and Dentofacial Orthopedics 2000
Author: Beccetti
Main purpose:
To assess the prevalence of associations between failure of eruption of permanent molars and other types of dental anomalies
-1520 patients with uncrowded dental arches (mean age 14)
-Occurrence of tooth anamolies in association with failure of the 1st and 2nd molars to erupt was assessed
-Assessment was compared to a control group of 1000 patients
-Anomalies included: infraocclusion of deciduous molars, palatal displacement of maxillary canines, rotation of maxillary laterals, peg laterals, and aplasia of second premolars
-Associations between unerupted 1st and 2nd molars and some tooth anomalies were highly significant (infraoccluded primary molars, palatally displaced canines, rotated maxillary laterals)
-No significant association was found with premolar aplasia and peg laterals
-These findings suggest a common biologic cause for these occurrences
It's interesting that these anomalies are found in association with each other. If an anomaly is found, it may be a good sign to be on the look-out for others.

Development of human craniofacial morphology during the late embryonic and early fetal periods

Resident: Derek Nobrega
Title: Development of human craniofacial morphology during the late embryonic and early fetal periods
Authors: VM Diewert, DDS, M.Sc.
Journal: American Journal of Orthodontics. July 1985. 41-53.

Main Purpose: To review major changes in craniofacial dimensions and spatial relations during the late embryonic and early fetal periods in order to understand the mechanisms of development of human facial morphology.

Methods: A quantitative morphometric evaluation of a large collection of staged embryos and fetuses in the Carnegie Embryological Collection.

Key Points:
- After formation of the primary palate during the 5th and 6th week post-conception, the secondary palate develops during the late embryonic period (7-8 weeks) and early fetal period (9-10 weeks).  
- Between 7-10 weeks post-conception when crown-rump length increased from 18-49mm, facial structures grew predominantly in the sagittal plane, with a four-fold increase in length, a two-fold increase in height, but little change in width. These changes altered relations of oronasal structures.
- The sagittal position of the maxilla and the mandible to the anterior cranial base increased, and the mandible was prognathic during secondary palate closure in the first 2 weeks of fetal development.
- Both the mean cranial base angulation and the achieved maxillary position were similar to the angulations present later pre-natally and post-natally.
- Human patterns of cranial base angulation and maxillary position appear to develop during the late embryonic period when the chondrocranium and Meckel’s cartilage for the continuous craniofacial skeleton.
- Rapid directional growth of the primary cartilages is important to development of normal human facial morphology and interference with normal growth changes during this early critical period may produce irreversible effects on the face.

This was a very comprehensive article on craniofacial growth and development. It was interesting to note that these early changes may have permanent effects on the face, and an inhibition of growth during this critical period may have irreversible effects that cannot be changed. 

Tuesday, January 22, 2013

Pinkham Tables 2-5 to 2-8

Resident: Derek Nobrega
Chapter: Table 2-5 to 2-8
Author: Catherine M Flaitz
Book: Pediatric Dentistry: Infancy Through Adolescence. Fourth Edition.

Soft Tissue Enlargements
Papillary Lesions
Squamous Papilloma
Single pedunculated nodule with fingerlike projections, pink to white
Tongue, lips, soft palate (but can be anywhere)
Excisional biopsy
Verruca vulgaris
Multiple sessile or pedunculated papules and nodules with rough surface, white
Skin of hands and face, infrequently on lip, labial mucosa, and anterior tongue. HPV 2, 4, 6, 40
Excisional biopsy
Condyloma acuninatum
Multiple sicrete sessile nodules with blunted papillary surface, pink
Anogenital lesons. HPV 2, 6, 11, 53, 54, 16, 18
Excisional biopsy
Giant cell fibroma
10-20, female
Solitary sessile pedunculated nodule with pebbly surface, pink
Attached gingiva, dorsal tongue, hard palate
Excisional biopsy
Focal epithelial hyperplasia (Heck’s Disease)
Multifocal sessile papules and nodules with pink grainy surface, lesions coalesce
Labial and buccal mucosa and tongue. HPV 13, 32
Excisional biopsy
Inflammatory Papillary Hyperplasia
Multiple clustered papules and nodules with pink to red granular surface
Hard palate.
Remove and clean appliance, reline if needed, antifungal therapy
Acute Inflammatory Lesions
Soft tissue abscess (Parulis)
Solitary pink-white or red nodule with surrounding erythema, purulent drainage
Gingiva and alveolar mucosa. Caused by odontogenic infection.
Manage source of infection, antibiotics
Diffuse erythematous swelling of sudden onset, warm and painful tissue
Upper or lower face and neck. Caused by odontogenic infection.
Manage source of infection, antibiotics, incision and drainage
Diffuse swelling of sudden onset, soft and nontender
Lips, tongue, soft palate and face. Allergic reaction.
Antihistamines, steroids, epinephrine,
Fluid-filled nodule with smooth translucent red or blue surface
Lower labial mucosa, buccal mucosa, anterior ventral tongue
Excisional biopsy with removal of underlying minor salivary glands
Fluid-filled swelling with smooth translucent to blue surface
Floor of mouth, lateral to midline. Associated with sublingual gland
Excisional biopsy of sublingual gland/
Tumor and Tumor-like Lesions
Irritation fibroma
Pedunculated or sessile nodule with pink smooth surface
Buccal and labial mucosa, tongue, attached gingiva
Conservative excisional biopsy
Peripheral Ossifying Fibroma
10-20, female
Pedunculated or sessile nodule with pink to red surface, frequently ulcerated
Interdental of attached gingiva, anterior most common
Excisional biopsy down to periosteum and remove local irritation
Peripheral Giant Cell Granuloma
10-20, female
Pedunculated or sessile nodule with red or purple-blue surface, may be ulcerated
Attached gingiva or alveolar mucosa
Excisional biopsy down to periosteum and remove local irritation
Pyogenic Granuloma
0-20, female
Pedunculated or sessile nodule with smooth to irregular red surface, bleeds easily, soft and friable
Attached gingiva, also on lip, tongue, buccal mucosa
Excisional biopsy and remove local irritation
Gingival Fibromatosis (Hereditary or Idiopathic)
Localized or generalized gingival enlargements, pink, smooth to stippled
Attached gingiva and maxillary tuberosity
Gingivectomy and good oral hygiene
Infancy, female
Localized to diffuse, red, blue or purple lesion, flat or nodular, bleeds easily
60% head and neck, lips, tongue, buccal mucosa
Involution of lesion within first decade
Infancy, most detected by 2 years
Localized ot diffuse translucent to red or purple swelling, smooth or pebbly surface
75% in head and neck, tongue, lip, buccal mucosa
Surgical excision, recurrence common
Congenital Epulis (Congenital Granular Cell Tumor)
Infancy, female
Pedunculated or sessile nodule, pink to red smooth surface
Anterior alveolar ridge, usually maxilla
Surgical excision
Single or multiple nodules with smooth surface, discrete or diffuse. Café-au-lait macules
Tongue, buccal mucosa, vestibule, and palate
Surgical excision if solitary, selective excision of syndrome type
Mucosal Neuroma (Multiple Endocrine Neoplasia Syndrom, Type 2B
Multiple pink papules and nodules, soft and non-tender, marfanoid body type
Labial and buccal mucosa, anterior tongue, gingiva
Surgical excision of neuromas for cosmetics
Pleiomorphic Adenoma (Benign Mixed Tumor)
10-20, female
Pink, dome shaped enlargement with smooth surface
Parotid gland most common, palate. Most common benign salivary gland neoplasm
Surgical excision with adequate margins
Juvenile Fibromatosis
Rapidly growing, pink firm mass with irregular surface, painless, large, facial disfigurement
Head and neck, paramandibular soft tissues
Surgical excision with wide margins

Radiolucent Lesions of Bone
Dentigerous Cyst
Well-defined, unilocular radiolucency around crown of unerupted tooth
Mandibular and maxillary third molar and canines
Enucleation, marsupialization if extensive
Odontogenic Keratocyst
10-20, male
Well-defined unilocular or multilocular radiolucency with corticated margins
Posterior body and ramus of mandible, maxillary 3rd molar and canines
Surgical excision, 30% recurrence
Ameloblastic Fibroma
0-20, male
Well-defined unilocular or multilocular lesion with sclerotic margins
Posterior maxilla and mandible
Surgical excision, 18% recurrence
Well-defined unilocular or multilocular radiolucency, cortical perforation, root displacement
Mandibular molar and ramus. Unicystic ameloblastoma is most common in children
Enucleation, 15% recurrence
Melanotic Neuroectodermal Tumor of Infancy
Rapidly expanding bony lesion, displacement of tooth buds, “floating tooth” appearance
Anterior maxilla
Surgical excision or curettage, 15% recurrence
Central Giant Cell Granuloma
0-20, female
Well-defined unilocular or multilocular radiolucency with scalloped border
Mandible, anterior to first molar, may cross midline
Thorough curettage, 20% recurrence
0-5, males
Chubby face, bilateral, symmetric enlargement of jaws
All four quadrants frequently involved
Controversial, spontaneous regression during puberty
Simple Bone Cyst (Traumatic Bone Cyst)
10-20, male
Well-defined unilocular radiolucency with thin sclerotic border scalloping between teeth
Posterior and anterior body of mandible and ramus
Surgical exploration and curettage
Aneurysmal Bone Cyst
Painful swelling with rapid growth, unilocular or multilocular radiolucency with ballooning distension of buccal cortex
Posterior mandible
Curettage or enucleation, 60% recurrence
Periapical Abscess
Nonvital mobile tooth, tender to percussion, soft tissue swelling with purulence
Primary dentition most frequently in children
Endo or extraction
Periapical Granuloma and Cyst
Nonvital tooth, asymptomatic, well or poorly defined lucency at apex, root resorption
Adjacent to root apex and furcation
Endo or tooth extraction and gently curettage
Acute Osteomyelitis
0-20, male
Diffuse radiolucency with poorly defined margins, sequestra, fever, swelling, pain
Posterior mandible in children, anterior maxilla in infants
Incision and drainage with culture testing
Langerhans Cell Histiocytosis (Histiocytosis X)
0-10 Disseminated form, 10-20 Localized Form
Lymphadenopathy, rash, oral pain, gingivitis, ulcers, mobile teeth, punched out radiolucencies, “floating tooth”, premature tooth loss
Skull, mandible, ribs, vertebrae
Chemotherapy, radiotherapy, surgical curettage
Burkitt’s Lymphoma
0-20, males
Lymphadenopathy, facial swelling, tenderness, tooth mobility, extrusion and premature loss
Posterior mandible
Chemotherapy, malignancy with 5-year survival

Mixed Radiolucent and Radiopaque Lesions of Bone
Calcifying Odontogenic Cyst (Gorlin’s Cyst)
Well-defined unilocular radiolucency with irregular calcifications or tooth-like structures, most associated with odontoma
Incisior-canine region of maxilla and mandible
Enucleation, minimal risk of recurrence
Adenomatoid Odontogenic Tumor
10-20, female
Well-defined unilocular radiolucency with fine snowflake calcifications
Anterior maxilla, anterior mandible
Ameloblastic Fibro-odontoma
Well-defined unilocular radiolucency with calcified material and tooth-like structures
Mandibular molar and premolar
Conservative curettage
Ossifying Fibroma (Cemento-ossifying fibroma)
Painless swelling, circular growth pattern, well-defined unilocular lesion with sclerotic border
Premolar and molar region, usually mandible
Enucleation or resection
Osteomyelitis with proliferative periostitis (Garre’s Osteomyelitis)
Diffuse, poorly defined mixed radiolucent and opaque lesion, cortical bone duplication with onion skin pattern
Posterior mandible, usually 1st permanent molar
Endo or extraction

Radiopaque Lesions of Bone
Odontoma, Compound and Complex
Well-defined radiopacity surrounded by narrow lucent rim.
Compound = mini teeth. Complex = amorphous mass
Compound – anterior maxilla
Complex – posterior mandible
Local excision
Solitary, well-defined spherical opacity.
Gardner Syndrome – multiple osteomas, intestinal polyposis, supernumerary teeth
Body of mandible and condyle
Surgical excision
Fibrous Dysplasia
Unilateral, fusiform enlargement, ground glass opacity with ill-defined borders. McCune-Albright syndrome – polyostotic fibrous dysplasia, cafe-au-lait macules
Maxilla>mandible, buccal and lingual cortical expansion
Osseous recontouring
Condensing Osteitis (Focal sclerosing osteomyelitis)
Localized opacity at root apices of pulpally involved tooth, margins blend into surrounding bone
Mandibular premolar and molar area
No treatment of bony lesion, manage odontogenic infection
Opaque mass surrounded by thin radiolucent rim, fused to root of vital tooth, pain and swelling
Posterior mandible in molar and premolar region
Surgical extraction of tooth with attached tumor or RCT with root amputation
Idiopathic Osteosclerosis
Asymptomatic, non-expansile, uniformly opaque lesion that blends into surrounding bone
Molar-premolar mandible, usually by root apices
No treatment neessary