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.     

Correlation between objective and subjective evaluation of profile in bimaxillary protrusion patients after orthodontic treatment

Objective:To correlate the objective cephalometric measurements with subjective facial esthetics in patients with bimaxillary protrusion.Materials and Methods:The sample consisted of 60 Asian-Chinese patients with bimaxillary protrusion who met the inclusion criteria. The facial esthetics of posttreatment profile and the change of profile on standardized lateral photographs were rated by a panel of 10 orthodontists and a panel of 10 lay persons with bimaxillary protrusion. All of the pretreatment and posttreatment cephalograms were digitized and traced. Twenty-five cephalometric measurements were constructed and analyzed. Correlations between the subjective facial esthetic scores and each cephalometric measurement were evaluated.Results:The cephalometric measurements correlated with the facial esthetic scores of posttreatment profile given by the orthodontist and the lay persons were basically the same. For the evaluation of posttreatment profile in bimaxillary protrusion patients, the upper and lower lip to E-line, upper and lower incisor tip to AP plane, Pg-NB distance, mentolabial angle, and sulcus depth correlated significantly with the esthetic score. For the evaluation of profile change during orthodontic treatment, retraction of upper incisor relative to AP plane or the perpendicular line through sella (line Y), change of upper incisor inclination, change of mentolabial sulcus depth, and retraction of lips relative to E-line were correlated positively with the esthetic value.Conclusions:Cephalometric measurements of lip position, incisor position, and chin morphology were key parameters correlated to facial esthetics.     

Value-addition of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning

ObjectiveTo investigate the value-addition of obtaining lateral cephalometric radiographs during the treatment planning phase of orthodontic treatment.Materials and MethodsThe records of 100 orthodontic patients were presented to seven scorers during two phases that were 6 weeks apart. In the first phase, scorers completed a seven-question survey with questions regarding treatment planning. They were given various diagnostic records that did not include a lateral cephalometric radiograph. Six weeks later, the same scorers completed the same survey for the same patient cases with the same diagnostic records that additionally included a lateral cephalometric radiograph. Correlation coefficients were used to calculate intrarater agreement and inter-rater agreement within the study.ResultsCohen''s kappa values showed moderate to almost perfect agreement for the majority of survey questions. Intrarater agreement ranged between 0.430 and 1. Cronbach''s alpha reliability statistics showed good interrater agreement for all questions in the survey. Agreement ranged from 0.710 to 0.913 across the survey questions. Diagnosing Angle classification of occlusion had the highest level of agreement and differentiating between skeletal and dental malocclusion had the lowest level of agreement.ConclusionsThe lateral cephalometric radiograph is not a necessary diagnostic tool for most cases in orthodontic diagnosis and treatment planning. Weighing the usefulness of a lateral cephalometric on a case-by-case basis should be recommended to align with the principle of ALARA (as low as reasonably achievable), especially in a primarily pediatric population.     

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.     

Gifts from orthodontists to general dentists

Objectives:To determine how often general dentists receive gifts from orthodontists, the value and number of the gifts they receive, and how they perceive the motivation behind the gift.Materials and Methods:This was a questionnaire-based study. A questionnaire was constructed and tested for validity and reliability. An electronic version of survey was sent via email to 1300 general dentists.Results:The validity and reliability of the survey was confirmed. Two hundred fifty-four valid responses were received (20%). Eighty-five percent of responding general practitioners reported that they received gifts from an orthodontist. Almost 100% reported that they referred patients to orthodontists. About one-third of the responding general practitioners reported that their office provided orthodontic care. There were statistically significant correlations between the number of annual patient referrals the general practitioners reported making and the number and value of the gifts they received from the orthodontists. Female general practitioners reported receiving a higher number of gifts of greater total value than male practitioners. General practitioners who reported providing orthodontic treatment did not differ from those who did not in the number of referrals they made annually and the number and value of the gifts they received. Quality of care was the most common reason general practitioners reported for their referral to an orthodontist. Forty-four percent of the responders reported that they received discounted orthodontic treatment.Conclusions:General practitioners refer patients to orthodontists and receive gifts from them. The number and value of the gifts reflects the number of referrals they make.     

Preventing and treating white-spot lesions associated with orthodontic treatment: a survey of general dentists and orthodontists

BackgroundThe authors investigated the prevention and treatment of white-spot lesions (WSLs) during and after orthodontic therapy from the perspective of general dentists and orthodontists.MethodsThe authors administered a cross-sectional survey to general dentists (n = 191) and orthodontists (n = 305) in Virginia, Maryland and North Carolina.ResultsSixty-nine percent of general dentists and 76 percent of orthodontists recommended in-office fluoride treatment for patients with severe WSLs immediately after orthodontic treatment. Sixty-nine percent of general dentists reported that they had treated WSLs during the previous year, and 37 percent of orthodontists reported that they had removed braces because of patients' poor oral hygiene. Sixty percent of orthodontists referred patients with WSLs to general dentists for treatment. Eighty-five percent of orthodontists responded that they encouraged patients to use a fluoride rinse as a preventive measure. More than one-third of general dentists indicated that severe WSLs after orthodontic treatment could have a negative effect on their perception of the treating orthodontist.ConclusionsWSLs are a common complication of orthodontic treatment and their presence can result in a negative perception of the treating orthodontist by the patient's general dentist.Clinical implicationsGeneral dentists and orthodontists should work together to prevent the development of WSLs in their patients. Treatment with fluoride supplements and motivating and training patients to practice good oral hygiene will help achieve this goal. Treatment after debonding should include the topical application of low concentrations of fluoride.     

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.     

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.     

Influence of orthodontic appliances on visual attention to smiling faces by eye-tracking evaluation

The influence of wearing orthodontic appliances on visual attention to smiling faces is not well understood. The purpose of this study was to investigate how laypeople viewed a frontal posed smiling face with orthodontic appliances compared with orthodontists. Frontal posed smiling facial photographs of 10 female models without an appliance or wearing clear tray, ceramic, or metal appliances were taken, and areas of interest (AOIs) for the eyes, nose, and mouth were determined. Visual attention from 43 laypeople and 42 orthodontists was evaluated for each image using an eye-tracking system. Total fixation time for each AOI was calculated and analyzed by three-way repeated measures analysis of variance and Tukey–Kramer multiple comparison tests (P < 0.05). The layperson group spent significantly more time looking at the mouth with ceramic and metal brackets than without brackets, similar to the orthodontist group (P < 0.001 and 0.001, respectively). Though the orthodontist group spent significantly more time looking at the mouth with metal brackets than the mouth with ceramic brackets (P < 0.040), no significant difference was noted in the layperson group. Under all appliance conditions, the layperson group spent significantly more and less time looking at the eyes and mouth than the orthodontist group, respectively (P < 0.001 and 0.001, respectively). These findings suggest that it may help patients who will start orthodontic treatment to understand an individual’s interest in the appearance of the orthodontic appliance, and orthodontists to counsel patients at the orthodontic appliance selection stage during the diagnosis.     

Comparison of perception of necessity of orthodontic treatment between orthodontists and dentists at dental check-ups with DAI

PurposeThe aims of this study were to examine the gaps in the perception of the necessity of orthodontic treatment between orthodontists and dentists, and identify the items influencing perception using the Dental Aesthetic Index (DAI).Materials and methodsBoth dentists and orthodontists assessed the necessity of orthodontic treatment in the 693 junior and senior high school students, and orthodontists examined the occlusion of the students with DAI. The data were analyzed with Student's t-test, Bonferroni multiple comparison test and decision analysis.ResultsIn the orthodontist’ perception, clearly significant differences were observed in all DAI items between necessary and unnecessary groups. However, maxillary missing teeth, mandibular missing teeth, spacing and diastema did not show a clear difference in the dentists’ perception. In the comparison of perception between orthodontists and dentists, crowding, largest anterior maxillary irregularity and largest mandibular irregularity showed significant differences. Decision analysis demonstrated that crowding was the most important item for both orthodontists and dentists.ConclusionThere were two types of gaps in the perception of the necessity of orthodontic treatment. The first one is an individual difference among the dentists, which is related to the evaluation of missing teeth and space in the dental arches. The other is recognized as gaps in the perception between orthodontists and dentists, which are related to the amounts of crowding. It is important to realize the difference of perception and improve the mutual understanding to prevent overlooking malocclusion.     

An Update on Orthodontic Manpower in Ireland

Abstract

There has been considerable debate in Europe over the past few years on manpower requirements in orthodontics. In some countries today the need for orthodontic care cannot be accommodated due to lack of professional manpower whereas in others a surplus of orthodontic treatment facilities exists. The aim of the present study was to establish a baseline for orthodontic demographics in the Republic of Ireland.

The number of orthodontists currently practising in Ireland was identified together with the number of Irish graduates currently on training programmes. Population figures were obtained from the Central Statistics Office.

The orthodontic manpower situation has altered dramatically in the Republic of Ireland over the past 20 years. The number of 12-year-olds per orthodontist has reduced over the past 18 years from 2773 in 1980 to 890 in 1998. The age profile of the orthodontists presently practising in Ireland is low with an expected retirement over the next 20 years of only 28 of the 69 orthodontists identified.

This study provides baseline information on orthodontic manpower in Ireland, and will facilitate Ireland's participation in similar or comparative studies in the future.     

The consultant orthodontic service--1996 survey.

OBJECTIVE: To evaluate the working patterns and facilities of the consultant orthodontist service. DESIGN: A cross-sectional survey. SETTING: Consultant orthodontist departments in the UK. SUBJECTS AND METHODS: All consultant orthodontists in the UK were sent a questionnaire that gathered information on the individual consultant, the facilities available, the new patients referred and patients under current treatment. RESULTS: The consultant orthodontist service provided treatment to a high number of patients who were in definite need of orthodontic treatment. A marked reduction in the use of removable appliances suggests improving standards of care and provision of more complex treatment. The caseload was high and a fair proportion of patients were returned to their referring dentists with treatment plans. The consultant service has not completely evolved into a service that provides treatment at a super-specialist level alone. CONCLUSIONS: There has been little change in the consultant orthodontist service over the past ten years. Arguably, this is because of the wishes of the purchasers and the shortage of trained orthodontic manpower as a direct result of poor manpower planning and lack of funds for post-graduate training.     

Evaluation of facial attractiveness for patients with malocclusion: A machine-learning technique employing Procrustes

Objective:To establish an objective method for evaluating facial attractiveness from a set of orthodontic photographs.Materials and Methods:One hundred eight malocclusion patients randomly selected from six universities in China were randomly divided into nine groups, with each group containing an equal number of patients with Class I, II, and III malocclusions. Sixty-nine expert Chinese orthodontists ranked photographs of the patients (frontal, lateral, and frontal smiling photos) before and after orthodontic treatment from “most attractive” to “least attractive” in each group. A weighted mean ranking was then calculated for each patient, based on which a three-point scale was created. Procrustes superimposition was conducted on 101 landmarks identified on the photographs. A support vector regression (SVR) function was set up according to the coordinate values of identified landmarks of each photographic set and its corresponding grading. Its predictive ability was tested for each group in turn.Results:The average coincidence rate obtained for comparisons of the subjective ratings with the SVR evaluation was 71.8% according to 18 verification tests.Conclusions:Geometric morphometrics combined with SVR may be a prospective method for objective comprehensive evaluation of facial attractiveness in the near future.     

Assessment of orthodontic treatment need: a comparison of study models and facial photographs

Abstract – Objectives: The current study aims to examine how orthodontic treatment need is prioritized depending upon whether dental study models or facial photographs are used as the means of assessment. Methods: A group of three orthodontists and three postgraduate orthodontic students assessed: (i) dental attractiveness; and (ii) need for orthodontic treatment in 40 subjects (19 males, 21 females). The 40 subjects displayed a range of malocclusions. Separate assessments were made from study models and facial photographs. Results: There was a bias towards higher scores for dental attractiveness from facial photographs compared with assessment of study casts, for all examiners. This was statistically significant for five of the six examiners (P = 0.001–0.101). The need for orthodontic treatment was rated as 20% higher from study models compared with facial photographs (P < 0.001); overall the level of need for orthodontic treatment was rated as 18.9% higher from study models compared with facial photographs (P < 0.001). Reproducibility analyses showed that there was a considerable variation in the intra‐ and inter‐examiner agreement. Conclusions: This study shows that a group of three orthodontists and three postgraduate students in orthodontics: (i) rated orthodontic treatment need higher from study models compared with facial photographs and; (ii) rated dental attractiveness higher from facial photographs compared with study models. It is suggested that the variable intra‐examiner agreement may result from the assessment of orthodontic treatment need and dental attractiveness in the absence of any specific assessment criteria. The poor reproducibility of assessment of orthodontic treatment need and dental attractiveness in the absence of strict criteria may suggest the need to use an appropriate index.     

Optimal dental and facial esthetics in orthodontics--a multifaceted challenge

The role of the orthodontist in resolving the patient's dental and facial esthetic concerns is a challenge due to the number of factors to be evaluated. The effect of growth and aging, and the existing dental, gingival, dentoalveolar, skeletal, and facial soft tissue components mandate a thorough investigation into all treatment options and modalities available to reach optimal esthetic goals. The orthodontist is further challenged with professional bias and patient bias and desires. Mounted study models, facial and intraoral photographs, cephalometric evaluation of dentoskeletal relationships, VTOs and STOs for trial treatment, computerized imaging, and clinical soft tissue evaluation are essential in proper diagnosis, treatment planning, execution of treatment, and assessment of post treatment results. With proper planning, the challenge of reaching dental and facial esthetic goals can be met without compromising the functional occlusal goals, periodontal health, TMJ health, and long term stability.     

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.     

Lateral facial profile may reveal the risk for sleep disordered breathing in children—The PANIC-study

Abstract

Objective. To evaluate the lateral view photography of the face as a tool for assessing morphological properties (i.e. facial convexity) as a risk factor for sleep disordered breathing (SDB) in children and to test how reliably oral health and non-oral healthcare professionals can visually discern the lateral profile of the face from the photographs. Materials and methods. The present study sample consisted of 382 children 6–8 years of age who were participants in the Physical Activity and Nutrition in Children (PANIC) Study. Sleep was assessed by a sleep questionnaire administered by the parents. SDB was defined as apnoeas, frequent or loud snoring or nocturnal mouth breathing observed by the parents. The facial convexity was assessed with three different methods. First, it was clinically evaluated by the reference orthodontist (T.I.). Second, lateral view photographs were taken to visually sub-divide the facial profile into convex, normal or concave. The photos were examined by a reference orthodontist and seven different healthcare professionals who work with children and also by a dental student. The inter- and intra-examiner consistencies were calculated by Kappa statistics. Three soft tissue landmarks of the facial profile, soft tissue Glabella (G`), Subnasale (Sn) and soft tissue Pogonion (Pg`) were digitally identified to analyze convexity of the face and the intra-examiner reproducibility of the reference orthodontist was determined by calculating intra-class correlation coefficients (ICCs). The third way to express the convexity of the face was to calculate the angle of facial convexity (G`-Sn-Pg`) and to group it into quintiles. For analysis the lowest quintile (≤164.2°) was set to represent the most convex facial profile. Results. The prevalence of the SDB in children with the most convex profiles expressed with the lowest quintile of the angle G`-Sn-Pg` (≤164.2°) was almost 2-fold (14.5%) compared to those with normal profile (8.1%) (p = 0.084). The inter-examiner Kappa values between the reference orthodontist and the other examiners for visually assessing the facial profile with the photographs ranged from poor-to-moderate (0.000–0.579). The best Kappa values were achieved between the two orthodontists (0.579). The intra-examiner Kappa value of the reference orthodontist for assessing the profiles was 0.920, with the agreement of 93.3%. In the ICC and its 95% CI between the two digital measurements, the angles of convexity of the facial profile (G`-Sn-Pg`) of the reference orthodontist were 0.980 and 0.951–0.992. Conclusion. In addition to orthodontists, it would be advantageous if also other healthcare professionals could play a key role in identifying certain risk features for SDB. However, the present results indicate that, in order to recognize the morphological risk for SDB, one would need to be trained for the purpose and, as well, needs sufficient knowledge of the growth and development of the face.     

Dental trauma: part 2. Managing poor prognosis anterior teeth – treatment options for the subsequent space in a growing patient

Abstract

Part 1 concentrated on implications of dental trauma especially prior to and during orthodontic treatment. This paper examines the literature supporting various treatment options for poor prognosis anterior teeth and subsequent space generated when these teeth are lost. The role of an interdisciplinary team in managing this clinical situation is essential to obtain optimal results and an orthodontist is an essential member. Although some treatment options are not provided by orthodontists it is important that they have some knowledge of these and the latest research that support their use. Other techniques lie very much within the orthodontic remit.

Treatment options can be split into maintaining the failing tooth or extraction and restoration of the edentulous gap. This paper reviews various treatment options including periodontal regeneration, surgical repositioning and distraction osteogenesis, composite build up to incisal levels and decoronation when maintaining a failing tooth. When extraction and restoration of edentulous gap is required the following treatment modalities are discussed: extraction technique to retain bone quantity, orthodontic space closure and opening (site development), autotransplantation, partial denture, resin bonded bridge and implants. All these options should be considered and available to an interdisciplinary team to ensure optimal care of children with anterior teeth of poor prognosis.     

Comparative study of cephalometric measurements using 3 imaging modalities

Background

The authors conducted a study to compare 2-dimensional (2D) lateral cephalometric radiography (LCR), 2D cone-beam computer tomographic (CBCT)–generated cephalogram and 3-dimensional (3D) CBCT for assessing cephalometric measurements.