Diagnostic performance of cheeks appearance in sleep apnea

Objective: Obstructive sleep apnea (OSA) is a common, potentially life-threatening, but underdiagnosed condition. The study aimed to test the role of facial myofunctional alterations in OSA screening.

Method: Sixty-one individuals with sleep complaints were evaluated by the Orofacial Myofunctional Evaluation with Scores (OMES) protocol before undergoing polysomnography. The performance of each of the protocol scores in OSA screening was tested.

Results: The nonparametric correlation of the apnea-hypopnea index (AHI) was significant for 18 of the 41 variables of the OMES protocol. Cheeks appearance had the best performance, increasing five times the odds for AHI ≥ 15. Its sensitivity was 66%; specificity, 72%; the area under the ROC curve, 0.69; positive and negative likelihood ratios, respectively, 2.38 and 0.47.

Discussion: Cheeks appearance may be an instantly visible surrogate of tongue and pharyngeal fat deposition and of muscle function in OSA screening. Adding the item “cheeks appearance” to OSA screening tools and questionnaires may be useful for the identification of OSA risk.     

Cephalometric risk factors associated with myocardial infarction in patients suffering from obstructive sleep apnea: A pilot case-control study

Introduction: Obstructive sleep apnea (OSA) and its craniofacial anatomic risk factors might play a role in several cardiovascular diseases, including myocardial infarction (MI). However, there are no data about cephalometric findings among OSA patients with MI.

Methods: In this pilot case-control study, about 2000 individuals referred to the sleep center were evaluated according to apnea – hypopnea index (AHI) and other inclusion criteria. Included were 62 OSA male patients (AHI > 10), of whom 6 had an MI history. In both control (n = 56) and MI groups (n = 6), 18 cephalometric parameters were traced. Data were analyzed using independent samples t-test.

Results: Compared with control OSA patients, OSA patients with MI showed a significantly larger tongue length (p = 0.015). The other cephalometric variables were not significantly different between the two groups.

Conclusion: An elongated tongue might be considered a risk factor for MI in OSA patients. The role of other variables remains inconclusive and open to investigation with larger samples (determined based on pilot studies such as this report) collected in longitudinal fashion.     

Cephalometric risk factors of obstructive sleep apnea

Introduction: Previous studies on risk factors of obstructive sleep apnea (OSA) are highly controversial and mostly identifying a few cephalometric risk factors.

Methods: OSA diagnosis was made according to the patients’ apnea-hypopnea index (AHI). Included were 74 OSA patients (AHI > 10) and 52 control subjects (AHI ≤ 10 + free of other OSA symptoms). In both groups, 18 cephalometric parameters were traced (SNA, SNB, ANB, the soft palate’s length (PNS-P), inferior airway space, the distance from the mandibular plane to the hyoid (MP-H), lengths of mandible (Go-Gn) and maxilla (PNS-ANS), vertical height of airway (VAL), vertical height of the posterior maxilla (S-PNS), superior posterior airway space (SPAS), middle airway space, distances from hyoid to third cervical vertebra and retrognathion (HH1), C3 (C3H), and RGN (HRGN), the maximum thickness of soft palate (MPT), tongue length (TGL), and the maximum height of tongue). These parameters were compared using t-test.

Results: Significant variables were SPAS (p = 0.027), MPT, TGL, HH1, C3H, HRGN, PNS-P, S-PNS, MP-H, VAL, and Go-Gn (all p values ≤ 0.006).

Conclusion: OSA patients exhibited thicker and longer soft palates, hyoid bones more distant from the vertebrae, retrognathion, and mandibular plane, higher posterior maxillae, longer mandibles, and smaller superior-posterior airways.     

Craniofacial growth: evolving paradigms

Aims:

Numerous theories about craniofacial growth have been formulated in the last century. The most influential hypotheses were: genetic, synthetic and functional matrix revisited. Moreover, a large number of experts from different fields tried to explain craniofacial growth and its developmental mechanisms, in order to deliver the best treatment possible to orthodontic patients. The aim of this review is to summarize recent concepts on craniofacial growth, overlap these theories with the development of the general scientific knowledge, and suggest a more integrated multidisciplinary person-based approach.

Methodology:

MEDLINE, EMBASE, Pubmed, CINAHL and Google Scholar were screened from inception to February 2014 for relevant papers. Grey literature was considered as part of the search.

Conclusions:

The influence of new scientific discoveries and intuitions about craniofacial growth produced further insights in orthodontics care, shifting the paradigm from a pre-determined, sectorial treatment to an individualized, multidisciplinary patient-centered approach aiming to enhance the quality of orthodontic assistance.     

Myhre syndrome: a rare craniofacial disorder

Aims:

Myhre syndrome is a rare disorder characterized by abnormal growth of the skeleton, muscles, and joints. The relationship of this syndrome to craniofacial growth and development is unknown. To the authors’ knowledge, this is the first Japanese case ever studied.

Methodology:

At 10 years and 7 months of age, the patient was referred to the Department of Pediatric Dentistry in the authors’ hospital, complaining of a dental problem.

Results:

The craniofacial region exhibited a long lower face, high and narrowed palate with submucous cleft palate, maxillary constriction, prognathism, open bite, and crowding of the dental arch. Some of these morphological disorders could be affected by the functional manifestations of muscular hypertrophy of the cheek region, muscle tenseness, or the low position of the tongue. General disorders of muscular hypertrophy, thickened bones, and limited joint mobility are consistent with craniofacial findings of muscle tension in the cheek region, thickened calvarium, and limitation of temporomandibular joint movement. The submucous cleft palate and crown deformation of the mandibular central incisor may be affected by dysfunctions of SMAD4 signaling.

Conclusions:

Craniofacial growth and development is affected by the general characteristics of Myhre syndrome, and could be important in its diagnosis.     

Rare case of giant unicystic ameloblastoma: Luminal variant

Objective and importance: Ameloblastoma is a locally aggressive benign tumor, commonly occurring in the mandible. While giant ameloblastoma of multicystic or plexiform variant have been reported, the authors report a rare case of giant unicystic ameloblastoma of luminal variant, which was treated by compartmental resection and planned for delayed reconstruction.

Clinical presentation: A 46 year old male patient reported to the oral surgery out-patient department with a swelling of the left side mandible region of 2 years duration. He had undergone ayurvedic treatment for the same with no improvement. The size of the lesion on presenting was approximately 9 × 12 cm.

Intervention: Compartmental resection with plan for secondary reconstruction, after adequate follow up period.

Conclusion: While conservative management is being explored as a treatment option for unicystic ameloblastoma, resection is still the standard of care regardless of the histopathological subtype for giant lesions.     

The craniofacial morphology and maximum bite force in sleep bruxism patients with signs and symptoms of temporomandibular disorders

Objectives:

The purpose of the present study was to compare craniofacial morphology and bite force of bruxist patients with signs and symptoms of temporomandibular disorders.

Method:

Fourteen subjects with sleep bruxism and 14 healthy subjects participated. The signs and symptoms of the temporomandibular disorders were identified according to the Craniomandibular Index (CMI). Maximum bite force was measured using strain-gage transducers. Lateral cephalometric films were taken, and linear and angular measurements were performed.

Results:

Bite force between bruxist and non-bruxist females was not significant, whereas males with bruxism revealed higher bite forces. None of the linear and angular measurements differed significantly between bruxist and non-bruxist males. However, higher mandibular corpus length and anterior cranial base length, and lower gonial angle were observed in bruxist females compared to non-bruxist females. Negative correlation between bite force and CMI values was found in both genders.

Discussion:

Bruxist females had higher CMI values than bruxist males, which could lead to relatively lower bite forces.     

A randomized cross over study comparing the efficacy of two mandibular advancement appliances in the treatment of mild-moderate obstructive sleep apnea

Objective: To compare efficacy, side effects, patient compliance, and preference between two types of custom-made mandibular advancement appliances (MAAs) in the treatment of patients with mild to moderate obstructive sleep apnea (OSA).

Methodology: This prospective, randomized, crossover study of 12 patients with mild to moderate OSA compared a titratable and a non-titratable MAA. Each patient was fitted with both appliances in a random order with a washout period of two weeks. Efficacy, side effects, compliance, and preference were evaluated by a questionnaire. All patients underwent overnight home sleep recordings prior to and after the use of each appliance in order to objectively assess sleep quality in terms of the apnea and hypopnea index (AHI), snoring frequency and oxygen desaturation index.

Results: Treatment successes (relief of symptoms and/or reduction of AHI to <10/h) were reported with both types of appliances. No compliance failure was reported, and in most patients, the side effects were mild, and improved with time.

Conclusion: Both types of oral appliances were effective treatments for patients with mild to moderate OSA, with fewer side effects and higher patient satisfaction.     

The prevalence of OSA in snorers presenting with various chief complaints: a pilot study

Aims:

The incidence of obstructive sleep apnea (OSA) in snoring patients is reported in the literature to range from 20% to 70%. The aim of this study was to obtain exact data on the percent of snorers who have OSA, and to classify them as having normal, mild, moderate, or severe sleep apnea.

Methodology:

There were 273 patients who came into the senior author’s office with sleep disorder breathing problems. They suffered with various sleep problems. All 273 patients also had a snoring problem. None of the 273 patients had ever had a sleep test, or polysomnograph (PSG).

All 273 required a PSG for evaluation of their sleep problem. They were referred to a certified sleep lab local to them. When the results of the PSG came back, the authors were able to classify them as having normal, mild, moderate, or severe sleep apnea.

Results:

The results of the 273 PSGs showed the following: 12 patients (4%) had PSGs of apnoea–hypopnoea index (AHI)<5 (normal), 57 patients (21%) had PSGs with AHIs 5–<15 (mild), 79 patients (29%) had PSGs with AHIs 15–<30 (moderate), 119 patients (44%) had PSGs 30 or >30 (severe), and 6 patients (2%) had PSGs >100 (severe).

Conclusions:

Based on this study, of 273 patients who snored, the incidence of OSA is high. Ninety-six percent of the patients suffered with mild to severe sleep apnea. This malady, which can be very serious and degenerating, could be much more prevalent than previously believed. Additional research is needed to verify these figures.     

Association between possible sleep bruxism and sleep characteristics in children

Aims: To evaluate the relationship between possible sleep bruxism and sleep characteristics in children.

Methodology: A cross-sectional study was conducted through data collection of a pre-tested questionnaire answered by 111 parents on behalf of their children in the waiting room during their appointment at the Pediatric Dentistry Clinic of a public Brazilian university. The diagnosis of possible sleep bruxism was based on the international classification of sleep disorders (ICSD) criteria. The Chi-square test and logistic multinomial regression test were used in the statistical analysis.

Results: The final model of logistic multinomial regression demonstrated that children with muscle pain in the mouth region (OR = 19.70 95% IC = 1.82–212.69), snoring (OR = 8.25 95% IC = 2, 56–26, 54), and those with parents with possible sleep bruxism have more of a probability of sleep bruxism.

Conclusion: Potential sleep bruxism tends to be hereditary. Muscle pain, snoring, and mouth breathing were important signals associated with possible sleep bruxism among children.     

Mandibular position influence on pilots’ postural balance analyzed under dynamic conditions

Objective: The aim of this study is to evaluate the influence of the mandibular position on the postural stability in a sample of civilian and military pilots.

Methods: Twenty military pilots (males, mean age 35.15 ± 3.14 years) and 17 civilian pilots (males, mean 34.91 ± 2.15 years) were enrolled in this study and underwent a Sensory Organization Test (SOT) using the EquiTest® (NeuroCom International Inc., Clackamas, OR, USA) computerized dynamic posturography. The composite parameter was recorded and analyzed.

Results: The equilibrium score (ES) recorded in centric occlusion is slightly higher than the ES recorded in mandibular rest position; civilian pilots showed ESs slightly higher than military pilots. The two-way ANOVA analysis shows these differences are not statistically significant.

Discussion: The findings of this study seem to suggest that the composite parameter of the SOT is not sensitive in analyzing the influence of the stomatognathic system on the postural balance of civilian and military pilots.     

How do patients perceive the British orthodontic society online information resource about orthognathic treatment? A qualitative study

Objectives: To explore the accessibility, usability and relevance of the British Orthodontic Society (BOS) online information resource (OIR), Your Jaw Surgery.

Design: Qualitative, cross-sectional study.

Setting: 5 UK sites.

Participants: Patients before, during and after treatment for non-cleft skeletal discrepancy.

Methods: Patients were identified at joint clinics and recruited after having time to view the OIR. Semi-structured interviews were conducted with 17 patients (aged 16–46 years). The interviews were transcribed and thematic analysis was undertaken using a framework approach.

Results: The main themes identified were the overall usefulness, personal relevance and positive perceptions of the OIR. The OIR was seen to be useful for patients considering treatment, and potentially useful for patients undergoing treatment. Participants were looking for a personally relevant resource that would give them the best possible idea of how they would look and feel after surgery. The OIR was perceived as trusted, positive and reassuring.

Conclusions: Patients at different stages of treatment found the OIR helpful and reassuring. Clinicians may find it useful to direct patients to the OIR to complement a professional consultation, but should be aware that patients may perceive it as presenting a positive image of the long-term benefits of orthognathic surgery.     

Temporomandibular disorder treatment in a patient wearing removable prostheses: A case report

Aim: The purpose of this intervention was to treat the patient, a 51-year-old woman, who was wearing a maxillary denture and a mandibular bilateral distal-extension partial denture (both unfit) and was suffering from temporomandibular disorder (TMD).

Methodology: The treatment suggested was to construct a superior repositioning splint (SRS), and after remission of the symptomatology, fabricate new dentures.

Results: The occlusal splint was effective and the symptomatology ceased after about five months of treatment. The new dental prostheses were made and followed up for 10 years with no return of the pain.

Conclusions: SRS and subsequent construction of new dentures after remission of the symptomatology was an effective treatment for TMD in the case described.     

Single-needle arthrocentesis (Shepard cannula) vs. double-needle arthrocentesis for treating disc displacement without reduction

Objectives: To compare single- vs. double-needle arthrocentesis with viscosupplementation for treating disc displacement without reduction of the temporomandibular joint.

Methods: Fifty-six patients with a magnetic resonance imaging diagnosis of non-reducing disc displacement were included. Arthrocentesis with viscosupplementation was performed on patients in group I using the Y-shaped needle (Shepard cannula) technique; the standard double-needle technique was performed on patients in group II. Patients were evaluated on postoperative day 1, and 1, 3, and 6 months later, patient- and procedure-related parameters were assessed.

Results: In both groups, significant improvement in the baseline levels was achieved (p < 0.01). Both techniques were equally effective at reducing pain and increasing the maximal mouth opening. The single-needle technique was easier to perform and required a shorter operative time (p < 0.01).

Discussion: Single-needle (Shepard cannula) arthrocentesis can be an alternative to the standard technique; however, it might add to the cost of the procedure.     

Distraction of the temporomandibular joint condyle in patients with unilateral non-reducing disc displacement: Fact or fiction?

Objectives: This study investigated the distractive effect of a unilateral pivot splint on patients with unilateral disc displacement without reduction.

Methods: The study group was comprised of 18 patients who had no history of treatment with removable prosthetic restorations of molars, premolars, or canine teeth, and no previous treatment for temporomandibular disorder. Joint spaces measurements made on magnetic resonance images indicated the affected side to be narrower than the healthy side. Unilateral distraction splints were made for all patients. An ultrasonic motion analyzer was used to measure the vertical shift occurring on the affected side as patients closed their mouths with maximal force with the splint in their mouths.

Results: Closing with maximal force on the unilateral distraction splint led to a noticeable downward movement of the affected condyle.

Discussion: The findings of this study indicate that the TMJ condyle of patients with unilateral disc displacement without reduction may be unilaterally distracted if the articular space is narrowed.     

A new device for measuring isometric force of the craniocervical flexor and extensor muscles and its reliability

Objective: Craniocervical (CC) muscles control posture of the CC area. Muscle imbalance at this area induces musculoskeletal disorders. The purpose of this study was to develop a device for measuring isometric force of CC flexor and extensor muscles and to evaluate its intra-rater reliability.

Method: Isometric force of CC flexor and extensor muscles was measured in 20 women by one examiner on two days with a custom-made device. The intra-class correlation coefficient (ICC), standard error of measurements (SEM), smallest detectable difference (SDD), and Pearson correlation coefficient were computed.

Results: The results of this study revealed that this device had excellent reliability (ICC: 0.98, SEM: 2.29 N, SDD: 6.36 N, Pearson correlation coefficient: 0.97 for CC flexor muscles and ICC: 0.97, SEM: 2.13 N, SDD: 5.91 N, Pearson correlation coefficient: 0.94 for CC extensor muscles).

Discussion: This new device can improve knowledge about the CC muscle and efficacy of treatments in patients with poor posture.     

The effects of stabilization splint treatment on the volume of masseter muscle in sleep bruxism patients

Objective: The aim of this study was to evaluate, quantitatively, the volumetric effects of stabilization splint therapy on the masseter muscle of sleep bruxism (SB) patients.

Methods: The magnetic resonance (MR) images of 16 SB patients diagnosed by polysomnography (PSG) who used stabilization splints for four months were obtained before and after the therapy. The masseter muscle volume was calculated using Cavalieri’s principle on the MR images.

Results: After the splint therapy, the mean volume of the masseter muscle did not reduce significantly. The fat and/or water content of the muscles did not change either.

Discussion: The stabilization splint therapy had no effect on the volume, fat and/or water content of the masseter muscle; however the discomfort was reduced in the patients. Although the effect of splint therapy is not fully understood, the non-invasive and reversible stabilization splint can be used in SB patients because of its relaxation effect on muscles.     

The Scottish Orthodontic Peer Review project: the outcome of treatment and standard of record keeping by orthodontic specialist practitioners in Scotland

Objectives: Assess occlusal outcomes of treatment and clinical record keeping in specialist practice in Scotland.

Design: A retrospective cohort study.

Setting: Specialist practices in Scotland.

Participants: Specialist orthodontists in Scotland.

Methods: Every specialist practitioner in Scotland (51) was invited to take part in the peer review project with 38 (76%) enrolled. Scotland was split into four geographical areas, and each practitioner matched with a colleague from the same area. Practitioners took one day to visit their colleague and score 30 consecutively treated NHS cases using the Peer Assessment Rating (PAR) index. They also assessed the quality of the records taken. Practitioners then swapped roles and assessed their partner’s occlusal outcomes and records.

Results: The mean pretreatment PAR score was 28.6 (SD 3.5). Mean posttreatment PAR score was 3.5 (SD 1.2). Mean reduction in PAR score was 25.1 (SD 3.8). Mean percentage PAR score reduction was 87.7% (SD 3.7%). Overall record keeping scores were written records 100%, study models 99.5%, Orthopantomogram radiograph 99.2%, photographs 86.3%, medical history 75% and consent 40.8%.

Conclusions: Occlusal outcomes achieved by specialist practitioners in Scotland were of a high standard. They maintained a good standard of clinical record collection in most areas examined.     

Mandibular movement during speech of two related Latin languages

Objectives/hypothesis: This study assessed the kinesiographic recordings of jaw movements during reading a text in Galician and Spanish language.

Study design: Cross-sectional blind study.

Methods: A homogeneous healthy group of 25 normal stomatognathic system and native Galician participants was studied. Frontal and parasagittal plane recordings of the intraborder lateral jaw movements and during reading Galician and Spanish texts were recorded using a calibrated jaw-tracking device, kinesiograph.

Results: Although movements were similar in both languages, a greater retrusion of the jaw in the Spanish language was shown; moreover, a tendency exists for a left-side motion envelope in this right-handedness preference sample.

Conclusions: This study supports the hypothesis that speech is controlled by the central nervous system rather than by peripheral factors and that the hemispheric dominance influences the asymmetry of the speech envelope.