Cephalometric analysis for the diagnosis of sleep apnea: a comparative study between reference values and measurements obtained for Brazilian subjects

OBJECTIVE: To verify if the reference values of Sleep Apnea cephalometric analysis of North American individuals are similar to the ones of Brazilian individuals presenting no craniofacial anomalies. The study also aimed to identify craniofacial alterations in Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) patients in relation to individuals without clinical characteristics of the disease through this cephalometric analysis. METHOD: It were used 55 lateral cephalograms consisting of 29 for the control group of adult individuals without clinical characteristics of OSAHS and 26 apneic adults. All radiographs were submitted to Sleep Apnea cephalometric analysis through Radiocef Studio 2.0. The standard values of this analysis were compared, by means of z test, to the ones obtained from the control group and these were compared to values from apneic group through Student's t test. RESULTS: There were no significant differences between values obtained from control group and standard values. On the group of OSAHS patients it was observed a decrease on the dimensions of upper airways and an increase on the soft palate length. CONCLUSIONS: The standard values of Sleep Apnea analysis can be used as reference in Brazilian individuals. Besides, through lateral cephalograms it was possible to identify craniofacial alterations in OSAHS patients.

Photographic assessment of cephalometric measurements

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Tendência de crescimento facial em ortodontia e ortopedia funcional dos maxilares

The knowledge of the facial growth trend is very important in orthodontic treatment. A lateral headfilm is recommended in all young patients undergoing a preorthodontic guidance program to anticipate the best time to begin any mechanical procedures and the possibilities to determine the type of facial growth trend. In type A it will be observed that the middle and lower face are growing forward and downward in unison, with no change in ANB angle. Type B growth trends reveals that growth is downward and forward, with the middle face growing forward more rapidly than the lower and in type C the lower face is growing downward and forward more rapidly than the middle face revealing a decrease in the size of the ANB angle.

Tratamiento de maloclusión classe II división 1 con el aparato de Herbst tipo férula, después del pico de crecimiento puberal

Malocclusion class II-1, is represented by a high prevalence in Brazil, being something common in orthodontic practice. One of the main characteristics of this malocclusion is jaw retrusion, by what many devices of jaw advance are presented in the literature. Being one of them Herbst's device, which is a functional and fixed device created by Emil Herbst (1905) and updated by Hans Pancherz in the decade of 80s.This device is characterized by keeping the jaw advance in a continuous way, while presenting a less active treatment, leading to an immediate aesthetic impact, and the patient cooperation is not required. To improve the anchoring and prevent the collapse of the apparatus was set up last amended version of it by Dr Raveli quoted as Herbst splint. Recent research indicates the use of this device after the peak pubertal growth, creating an appropriate response condylar. The aim of this work is to show the orthodontist a choice of how to use the splint Herbst in Class malocclusions II-1.

Eficiência do aparelho Herbst bandado na correção da Classe II divisão 1 -relato de caso

The current reports the case of a young patient with malocclusion Class II division 1 on permanent dentition treated in two stages, rthopedics and orthodontics, respectively. At first, the banded Herbst appliance was used duringa 7 months period, followed by a T4K appliance, Trainer for Kids used as retention, and on the second stage the corrective Orthodontics was performed. The results showed the acquirement of a Class I dental relationship, which was kept stable, with excellent intercuspation, even after 5 years of the removal of the Herbst appliance, as well as the correction of the overjet and the reduction of the facial profile convexity. It can be concluded that the Herbst appliance was very efficient in correcting the Class II malocclusion, long term, also providing a very favorable effect on the facial profile.

Estudo em telerradiografia em norma de 45º no tratamento da classe II com aparelho de Herbst

The aim of this retrospective study was to evaluate mandibular and maxillary changes induced by the use of Herbst applianceand by natural growth through oblique cephalometric radiographs in children with Class II division 1 malocclusion with mandibular retrusion. A sample of 49 individuals with age ranging from 8 to 10 years old (before growth peak) with Class II division 1, were into two groups: Herbst treated group (n=24) and control group (n=25). Both groups were paired for gender and chronological age. Statistical analysis was performed through Student’s t test. The Herbst appliance promoted the Class II correction in a 7 months period by mesialization of lower permanent first molars and distalization of upper permanent first molars. The Herbst appliance had no influence over the mandibular structure or the mandibular length. It was concluded that early treatment with Herbst appliance corrected the Class II malocclusion by means of dentoalveolar changes.

Alterações dentoesqueléticas verticais e horizontais induzidas pelo ativador elástico Aberto de Klammt

The aim of this study was to evaluate the vertical and horizontal dentoskeletal changes induced by the Klammt Open Elastic Activator in the treatment of the Class II Division 1 malocclusion. The sample of 34 children was divided into two groups of 17 subjects each (ten girls, seven boys), matched by age and gender and with an initial mean age of 8.5 years. The data was analyzed using a Student's t-test for intragroup and intergroup comparison. The results showed that the appliance promoted dentoalveolar restriction of the maxilar growth within normal anteroposterior and vertical growth of the maxillary apical base; increment in the vertical displacement the mandibular symphysis associated with normal horizontal growth of the mandible; palatal tipping of the upper incisors; restriction of the anterior migration of the upper molars; greater eruption pattern and normal anterior displacement of the lower incisors and molars. It was concluded that Klammt appliance induce changes that are predominantly horizontal dentoalveolar in upper arch and vertical dentoalveolar in lower arch and vertical skeletal changes in the mandible.

Tratamento da má-oclusão de classe II divisão 1 de Angle, com aparelho de Herbst splint metálico seguido de aparelho fixo, na dentição permanente

The Herbst appliance is currently one of the most used appliances for the correction of Class II division 1 with mandibular retrusion. When used in peak, or just after the peak of growth it can result in some skeletal gain, which is favorable to the correction of anteroposterior discrepancy with effective and stable results. This article aims to report a case of a patient with malocclusion Class II division 1 with mandibular retrusion, associated with maxillary protusion, treated in two stages: with Herbst splint metallic appliance followed by fixed appliance orthodontic treatment.

Estudo cefalométrico comparativo dos traçados predictivos e resultados ortodôntico-cirúrgicos em pacientes com face longa

The purpose of this research was to compare, by cephalometric analysis (McNamara and Legan & Burstone) the predictive tracings (by methods manual, and by softwares Dentofacial Planner Plus and Dolphin Image) with the post surgical results. Were selected the pre and post surgical lateral telerradiograph (six months after orthognatic surgery) of the 25 long face patients treated with combined orthognatic surgery. Were made the prediction tracings for each method and comparing cephalometrically with the post surgical results. This protocol was repeated once more for the error method evaluation, and the statistical was made by variance analysis and Tuckey overtest. The results show more frequency of the cephalometric values' aproximation of the post surgical results when the manual method (50% of the similarity with the post surgical result), followed of the DFPlus (31,2%) and Dolphin (18,8%) softwares. The experimental condition permits to conclude that the manual method had more precision, although the previsibility of the digital methods was reasonable satisfactory.

Lateral cephalometric diagnosis of asymmetry in Angle Class II subdivision compared to Class I and II

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts (R) total joint prostheses Part I - Skeletal and dental stability

The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total join, prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9 +/- 8.0 degrees. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9 +/- 3.5 mm at the lower incisor tips, 12.4 +/- 5.4 mm at Point B, 17.3 +/- 7.0 mm at menton, 18.4 +/- 8.5 mm at pogonion, and 11.0 +/- 5.3 mm at gonion. Vertically, the lower incisors moved upward -2.9 +/- 4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the rnaxillo-mandibular complex was a stable procedure for these patients at the longest follow-up.

Evaluation of the cervical vertebrae maturation index in lateral cephalograms taken in different head positions

The aim of this study was to evaluate if upward or downward head inclination might interfere with determination of the growth stage, using cervical vertebrae maturation index (CVMI), in order to verify the accuracy of such diagnosis when radiographs are taken with errors. Forty-nine patients, 26 females and 23 males, aged 9 to 15 years, were submitted to 3 lateral cephalograms: normal (NHP), with 15° upward head inclination (NHP-Up), and with 15° downward head inclination (NHP-Down). Three examiners evaluated the CVMI on the 147 cephalograms. The agreement among examiners was higher in the evaluation of cephalograms taken in NHP. The weighted Kappa test revealed moderate to substantial agreement between NHP and NHP-Up and between NHP and NHP-Down. There was greater agreement between NHP-Up and NHP-Down. It may be concluded that the evaluation of the CVMI on cephalograms in NHP is different as compared with radiographs taken with inclinations. Both NHP-Up and NHP-Down exhibited greater disagreement in the interpretation among examiners, since the evaluation method was not designed for cephalograms with positioning errors.

Relationship between the morphology of the maxillary central incisor and horizontal and vertical measurements of the face

Purpose: In order to assist in the selection of artificial teeth for complete dentures, this study aimed to assess the relationship between horizontal and vertical measurements of the face and the morphology of the maxillary central incisor. Materials and Methods: This was a study of 50 plaster casts and 100 teleradiographs - 50 in lateral norm and 50 in frontal norm, belonging to 50 individuals, Caucasian, with a naturally optimal occlusion, matching at least four of the six keys of Andrews. Images of the upper central incisors were obtained by scanning the plaster casts (three-dimensional) and subjectively classified by three examiners as oval, triangular or quadrangular. Facial measures (vertical and horizontal) were defined by means of teleradiographs. In order to check inter-examiner agreement on the classification of central incisor, the Kappa test was used. To verify whether data had normal distribution, the Kolmogorov-Smirnov test was used ( P > 0.2) was used. One-way analysis of variance was employed to assess the association between variables (P > 0.05). Results: When vertical measurements were compared with the three incisor shapes, there was no statistically significant difference (P > 0.05): Triangular (0.54), oval (0.63) and quadrangular (0.51). Similarly, no difference (P > 0.05) was found for facial width (139.08, 143.37, 141.65), maxillary width (76.68, 78.99, 76.91) and mandibular width (103.47, 105.50, 103.11). Conclusions: The majority of cases showed that horizontal and vertical measurements of the face cannot be used as a reference for determining the morphology of the maxillary central incisor crown. It is relevant to analyze and compare other morphological structures to improve the oral health-related quality of life for the conventional denture wearer.

Craniofacial morphology and sleep apnea in children with obstructed upper airways: Differences between genders

Objective: To correlate sleep apnea with craniofacial characteristics and facial patterns according to gender. Methods: In this prospective survey we studied 77 male and female children (3-12 years old) with an upper airway obstruction due to tonsil and adenoid enlargement. Children with lung problems, neurological disorders and syndromes, obstructive septal deviation, previous orthodontic treatment, orthodontic surgeries or oral surgeries, or obesity were excluded. Patients were subjected to physical examinations, nasal fiberoptic endoscopy, teleradiography for cephalometric analysis, and polysomnography. Methods: Cephalometric analysis included the following skeletal craniofacial measurements: facial axis (FA), facial depth (FD), mandibular plane angle (MP), lower facial height (LFH), mandibular arch (MA), and vertical growth coefficient (VERT) index. Results: The prevalence of sleep apnea was 46.75% with no statistical difference between genders. Among children with obstructive sleep apnea (Apneia Hypopnea Index - AHI >= 1) boys had higher AHI values than girls. A predominance of the dolichofacial pattern (81.9%) was observed. The following skeletal craniofacial measurements correlated with AHI in boys: FD (r(s) = -0.336/p = 0.020), MP (r(s) = 0.486/p = 0.00), and VERT index (r(s) = -0.337/p = 0.019). No correlations between craniofacial measurements and AHI were identified in girls. Conclusions: Craniofacial morphology may influence the severity of sleep apnea in boys but not in girls. (C) 2012 Elsevier B.V. All rights reserved.