Influence of lateral cephalometric radiography in orthodontic diagnosis and treatment planning

Objective:To evaluate the impact of additional lateral cephalometric radiography in orthodontic diagnosis and treatment planning.Materials and Methods:Forty-three patients seeking orthodontic treatment, and for whom pretreatment diagnostic records were available, were randomly selected. Ten qualified orthodontists were involved in this study. The patients'' records included three photographs of the angle trimmed dental casts, digital lateral cephalometric and panoramic radiographs, and standard clinical photographs comprising seven intra- and four extraoral pictures. Records were evaluated in two sessions. At the first session, orthodontists evaluated records without lateral cephalometric radiography (LCR). In the second session, the same information was presented, but with LCR. Between the two sessions the order in which the cases were presented was altered to avoid bias.Results:The percentage of agreement between sessions was lower for diagnosis than for treatment planning. Concerning skeletal classification, the least experienced orthodontist was the least consistent (28%), while the more experienced orthodontist was the more reliable (67%). In terms of treatment modalities, in general there was an agreement of 64%. The most frequent modifications in treatment modalities were seen in Class II malocclusion patients.Conclusions:The results of our study suggest that the majority of Portuguese orthodontists judge that LCR is important to producing a treatment plan. Despite that, it does not seem to have an influence on orthodontic treatment planning.     

Long-term skeletodental stability of mandibular symphyseal distraction osteogenesis: Tooth-borne vs hybrid distraction appliances

Objective:To evaluate and compare the long-term skeletodental stability of mandibular symphyseal distraction osteogenesis (MSDO) achieved with the use of tooth-borne vs. hybrid distraction appliances.Materials and Methods:Posttreatment and follow-up orthodontic records were collected for 33 patients. The 14 patients who underwent distraction with a tooth-borne appliance had a mean follow-up of 5.08 years. The 19 patients who underwent distraction with a hybrid appliance had a mean follow-up of 6.07 years. Records included intraoral photographs, study models, postero-anterior cephalometric radiographs, and lateral cephalometric radiographs. Total changes of 16 measurements were analyzed to compare patients who underwent the tooth-borne vs. the hybrid distraction.Results:Both groups shared several similar and significant (P < .05) changes from posttreatment to follow-up records. Cast analysis showed a decrease in intercanine width and arch length and an increase in irregularity index. The postero-anterior cephalometric radiograph showed an increase in the width of the interincisal apices. The lateral cephalometric radiograph showed a decrease in the MP-L1 angle. The only statistically significant difference between the two appliances was the intercentral incisor contact point.Conclusion:Changes found are consistent with those found in untreated and orthodontically treated individuals over time. The long-term changes in the current patient sample can be determined to be expected and acceptable. MSDO is a viable treatment option with the use of either a hybrid or tooth-borne appliance.     

Contribution of pretreatment radiographs to orthodontists' decision making

A study was conducted to determine the amount of diagnostic and treatment planning information gained by orthodontists when pretreatment radiographs are added to a set of orthodontic records. Thirty-nine orthodontists evaluated six test cases and formulated a diagnosis and treatment plan. Information was collected about the participants' certainty with their diagnoses and treatment plans, the impact of the radiographs, the number and type of radiographs that were selected, and the difficulty of each case. Results showed that orthodontists were approximately 75% confident of their diagnosis before reviewing any radiograph. There were 741 radiographs ordered, of which 192 produced changes to the diagnostic process. The lateral cephalometric radiograph was the most productive. Panoramic and full-mouth series were productive but provided largely duplicative information.     

The influence of cephalometrics on orthodontic treatment planning

Since its introduction, cephalometrics, i.e. cephalometric radiography and analysis, has been used for orthodontic treatment planning. However, the effectiveness of this diagnostic method remains questionable. A randomized crossover study was designed to assess the influence of cephalometrics in orthodontic treatment planning of individual patients. Diagnostic records of 48 subjects (24 males and 24 females aged 11-14 years) were divided in two stratified groups and assigned to one of two combinations: A, dental casts only, and B, dental casts, cephalometric radiographs, and analysis. The records were presented to 10 orthodontic postgraduates and four orthodontists for formulation of orthodontic treatment plans containing a dichotomous decision regarding the use of a functional appliance (FUNC), rapid maxillary expansion (RME), and extraction (EXTR). The combination of FUNC + RME + EXTR was used as the basis of the outcome measure. Agreement on orthodontic treatment planning using all possible comparisons of diagnostic records of individual patients (AB, AA, and BB) was assessed and overall proportions of agreement (OPA) were calculated for orthodontic postgraduates and orthodontists separately. Median OPA were 0.60 (AB), 0.65 (AA), and 0.60 (BB) for orthodontic postgraduates and 0.50 (AB), 0.75 (AA), and 0.50 (BB) for orthodontists. Irrespective of the level of experience, neither consistency of orthodontic treatment planning between both combinations of diagnostic records showed a statistically significant difference (P > 0.05) using Wilcoxon signed rank test nor did consistencies and agreement of orthodontic treatment planning after the addition of cephalometrics. It appears that cephalometrics are not required for orthodontic treatment planning, as they did not influence treatment decisions.     

Concurrent validity and reliability of cephalometric analysis using smartphone apps and computer software

Objectives:To assess the diagnostic accuracy of two smartphone cephalometric analysis apps compared with Viewbox software.Materials and Methods:Pretreatment digital lateral cephalograms of 50 consecutive orthodontic patients (20 males, 30 females; mean age, 19.1 years; SD, 11.7) were traced twice using two apps (ie, CephNinja and OneCeph), with Viewbox used as the gold standard computer software program. Seven angular and two linear measurements, originally derived from Steiner cephalometric analysis, were performed.Results:Regarding validity, intraclass correlation coefficients (ICCs) ranged from .903–.983 and .786–.978 for OneCeph vs Viewbox and CephNinja vs Viewbox, respectively. The ICC values for intratool reliability ranged from .647–.993. None of the CephNinja measurements was below the recommended cutoff values of ICCs for reliability.Conclusions:OneCeph has a high validity compared with Viewbox, while CephNinja is the best alternative to Viewbox regarding reliability. Smartphone apps may have a great potential in supplementing traditional cephalometric analysis.     

Precision of measurements on conventional negative 'bones white' and inverted greyscale 'bones black' digital lateral cephalograms

The objective of this study was to determine whether the accuracy of measurement data from inverted greyscale digital cephalometric radiographs equals that obtained from conventional negative digital cephalometric radiographs. Fifty-five consecutively lateral cephalometric radiographs from a university orthodontic clinic obtained for treatment planning were used for this study. A 5 MB conventional negative 'bones white' and inverted greyscale 'bones black' TIFF digital image of each radiograph was produced. These were allocated a unique identifier and were analysed in random order by one clinician. Eighteen cephalometric landmarks were digitized using the Opal 2.1 package and the angles were calculated. The angular measurements were compared using two-sample t-tests (P < 0.05). The angular measurements from the conventional negative bones white and inverted greyscale bones black lateral cephalometric radiographs were neither statistically significantly different nor clinically different from each other. Therefore, measurements derived from conventional negative bones white and inverted greyscale bones black lateral cephalometric radiographs have a similar level of precision.     

Radiographic examinations as an aid to orthodontic diagnosis and treatment planning.

Seventy consecutive adolescents were examined to evaluate radiographic examinations as an aid to orthodontic diagnosis and treatment planning in combination with clinical examination. The clinical examination included dental impressions and extra- and intraoral photographs. The radiographic examination comprised a panoramic radiograph, a lateral cephalogram and six intraoral anterior periapical radiographs. Initially, only records from the clinical examination were used for diagnosis and treatment planning. If required, the dentist could choose any of the radiographs to accomplish the task. The number of radiographs ordered, the sequence of ordering and any change in diagnosis and treatment plan caused by the radiographs were registered. In 29% of the cases the initial diagnosis, based on the clinical examination, study models and photographs, coincided with the final diagnosis. In 93% of all cases the initial treatment plan coincided with the final one. Although the panoramic examination was the most common choice, it had only a minor effect on diagnostic and treatment decisions, while the cephalometric examination had a major impact on the diagnosis. In most cases the clinical examination, supplemented with study models and photographs, can provide adequate information for orthodontic treatment planning. The result stresses the importance of using individually based selection criteria for radiographic examination in order to prevent radiographs being obtained routinely.     

Determination of Holdaway soft tissue norms for the North Indian population based on panel perception of facial esthetics

IntroductionThe purpose of this study was to determine Holdaway soft tissue norms for the North Indian population based on panel perception of facial esthetics.Material and method90 individuals (45 males and 45 females) from the North Indian population with normal anteroposterior and vertical skeletal relationships on analysis of lateral cephalometric radiographs were selected for the study. The landmarks were located according to the definitions of Holdaway. Ten linear and two angular measurements were analysed on each radiograph. For each variable, the arithmetic mean and standard deviation were calculated. For statistical evaluation, an independent-samples t test was performed.ResultsExcept for the measurements of soft tissue chin thickness, H angle and nose prominence all soft tissue measurements were similar to Holdaway norms. For upper lip thickness, soft tissue chin thickness, skeletal profile convexity and basic upper lip thickness measurements, statistically significant sex differences were determined.ConclusionsBased on this study, new soft tissue norms are established for orthodontic and surgical diagnosis and treatment planning.     

The Cortical Boundary Line as a Guide for Incisor Re-positioning with Anterior Segmental Osteotomies

Anterior alveolar anatomical constraints involving presurgical orthodontic incisor repositioning are often unrecognized and overlooked during orthodontic-surgical treatment planning. A clear discrimination of this cortical limitation is invaluable during the planning stage as it permits the consideration of alternative approaches like the anterior maxillary osteotomy for effecting the required incisor movement. A simple reference line termed the “Cortical Boundary Line” is introduced to facilitate the clinical translation of this information and through suitable case illustrations, the construction of the reference line using the conventional lateral cephalometric radiograph and its usefulness as an adjunct in aiding decisions on orthodontic incisor decompensation is highlighted.     

Craniofacial morphology and tooth wear: a longitudinal study of orthodontic patients

Previous research has suggested that a relationship exists between craniofacial morphology and tooth wear. The primary objective of this study was to determine whether an individual's craniofacial morphology during childhood is related to the degree of tooth wear that occurs in that same individual's adult dentition. Pretreatment orthodontic records taken during the mixed dentition (T1) and follow-up records taken an average of 20 years later (T2) were available for 165 orthodontic patients. Incisal/occlusal tooth wear was measured on a tooth-by-tooth basis from T1 and T2 casts using a four-category scoring system. Measures of craniofacial morphology were made from the T1 lateral cephalometric radiograph. Multiple regression analysis indicated that adult wear was associated with the T1 cephalometric measures of ANB (p = 0.017) and the interaction between ramal height and sex (p = 0.039). These results suggest that the craniofacial morphology observed during childhood has a small but significant relationship to adult tooth wear.     

A comparison of treatment results of adult deep-bite cases treated with lingual and labial fixed appliances

ObjectivesTo compare the cephalometric treatment results of adult deep-bite cases after labial and lingual fixed orthodontic treatment.Materials and MethodsA total of 102 patients underwent lingual orthodontic treatment and complete records were evaluated. The following inclusion criteria were used: patients who had Angle Class I or mild Class II malocclusion; comprehensive orthodontic treatment that did not include intrusion mechanics or any extractions; patients with an initial overbite of more than 3.7 mm. Thirteen patients met the inclusion criteria. These cases were matched with the same number of patients according to age with a labial orthodontic treatment group. Pre- and post-treatment cephalometric radiographs were evaluated. Independent t test or Fisher exact tests were performed to assess the differences between the groups.ResultsProclination of the upper incisors was higher in the labial group. Incisor mandibular plane angle (IMPA) showed an increase of 1.2° in the lingual group and 9.7° in the labial group. Lower incisor edge was approximately in a stable sagittal position in the lingual group but significant lower incisor proclination was seen in the labial group. The lower incisors were intruded (-1 mm) in the lingual group but lower incisors were minimally extruded (0.3 mm) in the labial group. No significant difference was found in the movements of upper and lower molars for both groups.ConclusionsThe nature of lower incisor movement involved less protrusion in lingual orthodontics than the labial treatment. Lingual orthodontic treatment is a better option in adult cases where intrusion of lower incisors without labial tipping is desired.     

Consistency of orthodontic treatment decisions relative to diagnostic records

The purpose of this study was to evaluate how incremental information obtained from different types of diagnostic records contributes to the determination of orthodontic treatment decisions. Pretreatment records of 57 orthodontic patients were assessed by five orthodontists who were part-time faculty members and also in private practice. This sample consisted of dental school orthodontic patients who had Class II malocclusions and included patients at three different dental developmental stages. The following diagnostic records were used: study models (S), facial photographs (F), a panoramic radiograph (P), a lateral cephalogram (C), and its tracing (T). Five combinations of diagnostic records were presented to the orthodontists in the following sequence: (1) S; (2) S + F; (3) S + F + P; (4) S + F + P + C; and (5) S + F + P + C + T. The simultaneous interpretation of all diagnostic records (S + F + P + C + T) was used as the "diagnostic standard." There was a diagnostic standard for each of the patients and for each of the orthodontists. The diagnostic standard was achieved: (1) S = 54.9%, (2) S + F = 54.2%, (3) S + F + P = 60.9%, and (4) S + F + P + C = 59.9%. Thus, in a majority of cases (55%), study models alone provided adequate information for treatment planning, and incremental addition of information from other types of diagnostic records made small differences.     

Relationship between anterior occlusion and frontal sinus size

Objective:To determine the relationship between anterior occlusion and frontal sinus size.Methods:The patient database at the Eastman Institute for Oral Health, University of Rochester, was searched for male patients older than 15 years and females older than 13 years of age. After applying inclusion and exclusion criteria, participants'' photos and lateral cephalometric and posteroanterior radiographs were examined then classified into a control class I group (n = 20, 15.7 ± 2.7 years) and eight malocclusion groups (n = 136, 16.1 ± 2.1 years). The frontal sinus area on the lateral cephalometric radiograph and on the posteroanterior radiograph were measured and compared between groups.Results:One-way analysis of variance demonstrated a significant difference among all nine groups (P = .0001). Pairwise comparison showed a significant difference between the class I group and all other malocclusion groups (P < .05) except the edge-to-edge group for both radiographs and except the bimaxillary protrusion group for the lateral cephalometric radiographs. Tukey''s method was not able to demonstrate a significant difference among the subgroups of skeletal malocclusions (P > .05). Linear regression analyses with stepwise model selection demonstrated that anterior cranial base, mandibular plane angle, and upper incisor inclination commonly have a significant effect on frontal sinus size.Conclusion:The frontal sinus size could be used as an indicator of harmonious anterior occlusion. There were no differences among the subgroups of each skeletal malocclusion. The anterior cranial base, facial height, and maxillary incisor inclination appear to have a significant effect on frontal sinus size.     

Diagnostic protocol in cases of congenitally missing maxillary lateral incisors

Patients with congenitally missing maxillary lateral incisors may seek treatment from an orthodontist for several reasons; unpleasant smile, dental arch disharmony, and midline deviations are among the most frequent complaints. Orthodontists and prosthodontists have raised important questions about the esthetics, occlusion, periodontal health, and psychological conditions noted in these patients. The decision to open lateral incisor spaces for prosthetics or close spaces by mesial movement of the canines requires a careful diagnosis and comprehensive multidisciplinary treatment planning. The purpose of this article is to present a diagnostic protocol to assist in the decision-making process, while analyzing patients with absent maxillary lateral incisors. The basis for a sound diagnosis and an effective treatment plan resides in careful consideration of the facial and dental characteristics of each patient. All information gathered during the clinical examination should be added to data obtained with other diagnostic tools, such as cephalometric analysis and orthodontic waxups, to achieve the treatment option that best suits the patient's expectations.     

Impact of pediatric obstructive sleep apnea on the development of Class II hyperdivergent patients receiving orthodontic treatment: A pilot study

Objectives:To conduct a pilot study to determine if the presence of obstructive sleep apnea (OSA) influences the orthodontic treatment outcome of Class II hyperdivergent patients receiving comprehensive orthodontic treatment.Materials and Methods:Patients between the ages of 12 and 14 who received orthodontic treatment at the Hospital of Stomatology, Wuhan University, China, were included in this study. Patients were divided into two groups: the OSA group and the control group, based on the outcome of pretreatment polysomnography findings and lateral cephalometric radiograph examination. Patients in the control group were matched with the OSA group for age, sex, ethnicity, weight, and height. Cephalometric measurements were used to record the skeletal and dental changes from before to after treatment. Data were analyzed using the t-test.Results:Twenty three OSA patients and 23 control patients were included. After comprehensive orthodontic treatment, the mandibular plane angle (SN-GoMe), articular angle (SArGo), sum of Jarabak angles (SUM) and the lower gonial angle (NGoMe) were found to increase significantly in the OSA group but remained unchanged or decreased slightly in the control group (P < .05). In the non-OSA group, the growth pattern became more horizontal. In contrast, in the OSA group the growth pattern became more vertical. Otherwise, similar treatment results were obtained for both groups in terms of sagittal change and occlusion.Conclusions:The presence of OSA in pediatric patients has a deleterious effect on the development of hyperdivergent malocclusions. Early diagnosis and management of pediatric OSA can affect the orthodontic treatment outcome of these patients.     

Radiation reduction using a modified collimated lateral skull radiograph during orthodontic treatment

The aim of the study was to investigate whether routine 'during-treatment' clinical cephalometric measurements could be obtained from a lateral skull radiograph collimated to show the maxilla and mandible. The sample consisted of 30 lateral skull radiographs, taken during treatment, of patients with upper and lower fixed appliances. These conventional cephalograms (CC) were copied to give a radiograph with modified collimation (MC) showing the maxilla and mandible and the dentition only. Both types of radiographs were digitised and the readings compared to determine whether the same during-treatment cephalometric values were obtained from both types of radiographs. The limits of agreement obtained, when comparing cephalometric values obtained from the CC and MC lateral skull radiographs, were only marginally larger than those for CC alone. Therefore, the use of an MC lateral skull radiograph to show the maxilla and mandible is a viable alternative for cephalometric measurements for patients wearing two arch fixed appliances.     

Is there a relationship between mandibular cortical bone thickness and orthodontic treatment time?

ObjectivesTo determine whether there was a correlation between patients'' bone thickness and time spent in orthodontic treatment. The secondary aim was to study the influence of Angle classification, extraction treatment, and age on overall treatment duration.Materials and MethodsIn this retrospective study, records of 971 orthodontic patients from two centers were reviewed and 500 subjects were included after imposing inclusion/exclusion criteria. The Mental Index was used to determine patients'' bone density. For the Mental Index, a line perpendicular to the inferior border of the mandible was drawn on a panoramic radiograph so that it intersected the inferior border of the mental foramen. The mandibular cortical thickness was measured along this line. Two-sample t-test or a chi-square test, followed by multiple linear regression, were used to identify the factors affecting treatment duration.ResultsMandibular cortical thickness was negatively associated with treatment time for all subjects (P < .05). After adjusting for covariables, it remained significant for center-1, but non-significant for center-2 subjects. Angle Class II and Class III malocclusion, extraction therapy, and age had significant positive correlations with treatment duration (P < .05).ConclusionsThere is a negative correlation between the mandibular cortical thickness and orthodontic treatment duration. An extraction treatment plan and treatment of Angle Class II and Class III malocclusions significantly increase the duration of orthodontic treatment. Additionally, patients over 12 years of age have shorter treatment times compared to patients under 12 years of age.     

An assessment of conventional and self-ligating brackets in Class I maxillary constriction patients

Objective:To evaluate two different treatment systems with regard to incisor position, transverse dimension changes in maxillary arch, changes in maxillary molar inclinations, clinical periodontal parameters, and pain intensity in patients with a Class I malocclusion.Materials and Methods:Seventeen patients (with a mean age of 14.5 years) underwent orthodontic treatment with the Roth prescribed edgewise bracket systems after expanding the maxillary arch with a quad-helix appliance, and 16 patients (with a mean age of 14.8 years) underwent orthodontic treatment with the Damon 3MX bracket system. Each subject''s lateral cephalometric and posteroanterior radiographs and dental casts were obtained at the beginning of the treatment and after debonding. In addition to these, the periodontal index and pain scores were taken.Results:Cephalometric data showed that in both treatment systems, overjet value decreased and maxillary and mandibular incisors proclined. Posteroanterior measurements demonstrated a greater increase in the maxillary molar inclination in the Damon group. Significant increase of maxillary intercanine, interpremolar, and intermolar widths was shown in both systems. Periodontal index and pain score changes between different observation periods were the same.Conclusions:The conventional and Damon systems were found similar with regard to the incisor position, transverse dimension changes in maxillary arch, clinical periodontal parameters, and pain intensity. The only significant difference was that the Damon system inclined the maxillary molars more buccally than the conventional group.     

Interexaminer reliability of two cephalometric methods to determine proximal segment position after bilateral sagittal split ramus osteotomy

The objective of this study was to evaluate the interexaminer reliability of two cephalometric methods for determining positional change of the proximal segment after a bilateral sagittal split ramus osteotomy (BSSRO) for mandibular advancement. The records of 25 patients were used in a double-blind trial. Two nontrained investigators (having read the articles describing the two cephalometric methods, but with no other special training) independently traced posterior-anterior (PA) and lateral cephalometric radiographs taken at three time intervals: (T1) before surgery, (T2) immediately after surgery, and (T3) after orthodontic treatment was completed. The level of agreement between the two investigators (interexaminer reliability) on all 25 patients was estimated by calculating the intraclass correlation coefficient (ICC). The ICC was found to have a high value, indicating "substantial" to "almost perfect agreement" between the two examiners. Thus the results validate the use of these two methods to determine proximal segment positional changes in the frontal and sagittal planes of space after a BSSRO.