An alternative treatment approach for patients with resistant otitis media with effusion and dysfunctional Eustachian tube: A pilot study with rapid maxillary expansion

ABSTRACT Objectives To determine whether dysfunctional Eustachian tubes of children with resistant otitis media with effusion (OME), ventilation tube placement indication, and maxillary constriction will recover after rapid maxillary expansion (RME). Materials and Methods The RME group consisted of 15 children (mean age: 10.07 years) with maxillary constriction, Eustachian tube dysfunction (ETD), and resistant OME. The control group consisted of 11 healthy children (mean age: 8.34 years) with no orthodontic and/or rhinologic problems. Recovery of Eustachian tube dysfunction was evaluated by Williams' test at three timepoints: before RME/at baseline (T0); after RME (T1); and after an observation period of 10 months (T2). The control group was matched to all these periods, except T1. Results In the control group, functioning Eustachian tubes were observed in all ears at baseline (T0), and tubes showed no worsening and no change during the observation period (T2) (P > .05). In the RME group, functioning Eustachian tubes were observed in eight of 30 ears and ETD was observed in the remaining 22 ears at baseline (T0). The RME group showed significant improvements in tube functions after RME and the observation period (P < .05). Fifteen of 22 dysfunctional ears recovered (68.2%) and started to exhibit normal Eustachian tube function after RME (T1) and the observation period (T2). Conclusions The findings suggest that ears having poorly functioning Eustachian tubes are restored and recovered after RME in most of children with maxillary constriction and resistant OME. Thus, RME should be preferred as a first therapy alternative for children with maxillary constriction and serous otitis media.

Comparison of Tooth- and Bone-Borne Appliances on the Stress Distributions and Displacement Patterns in the Facial Skeleton in Surgically Assisted Rapid Maxillary Expansion—A Finite Element Analysis (FEA) Study

The aim of this study was to compare the reduced stresses according to Huber’s hypothesis and the displacement pattern in the region of the facial skeleton using a tooth- or bone-borne appliance in surgically assisted rapid maxillary expansion (SARME). In the current literature, the lack of updated reports about biomechanical effects in bone-borne appliances used in SARME is noticeable. Finite element analysis (FEA) was used for this study. Six facial skeleton models were created, five with various variants of osteotomy and one without osteotomy. Two different appliances for maxillary expansion were used for each model. The three-dimensional (3D) model of the facial skeleton was created on the basis of spiral computed tomography (CT) scans of a 32-year-old patient with maxillary constriction. The finite element model was built using ANSYS 15.0 software, in which the computations were carried out. Stress distributions and displacement values along the 3D axes were found for each osteotomy variant with the expansion of the tooth- and the bone-borne devices at a level of 0.5 mm. The investigation showed that in the case of a full osteotomy of the maxilla, as described by Bell and Epker in 1976, the method of fixing the appliance for maxillary expansion had no impact on the distribution of the reduced stresses according to Huber’s hypothesis in the facial skeleton. In the case of the bone-borne appliance, the load on the teeth, which may lead to periodontal and orthodontic complications, was eliminated. In the case of a full osteotomy of the maxilla, displacements in the buccolingual direction for all the variables of the bone-borne appliance were slightly bigger than for the tooth-borne appliance.

The Impact of Maxillary Expansion on Adults’ Nasal Breathing: A Systematic Review and Meta-Analysis

Objective Nasal surgery fails to restore nasal breathing in some cases. Maxillary constriction is suggested as a major cause of failure. It is thought that maxillary constriction leads to the closure of the internal and external nasal valves. Moreover, it is well established in the literature that maxillary expansion, both in adults and children, increases upper airway volume. However, it is yet unclear whether maxillary expansion may improve nasal function. Review Methods: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked by two authors from the Rhinology Study Group of the Young Otolaryngologists section of the International Federation of Otorhinolaryngological Societies. Two authors extracted the data. The main outcome was expressed as the value (in variable units) prior to treatment (T0), after expansion procedures (T1), after the retention period (T2), and after a follow-up period (T3). Results A total of 10 studies (257 patients) met the inclusion criteria. The data pooled in the meta-analysis reveals a statistically significant reduction of 0.27 Pa/cm3/s (CI 95% 0.15, 0.39) in nasal resistance after palatal expansion As far as subjective changes are concerned, the pooled data for the change in the NOSE score shows a statistically significant mean reduction after maxillary expansion of 40.08 points (CI 95% 36.28, 43.89). Conclusion The initial available evidence is too limited to suggest maxillary expansion as a primary treatment option to target nasal breathing. However the data is encouraging with regards to the effect of maxillary expansion on nasal function. Further higher quality studies are needed in order to define clearer patient selection criteria, distinguish optimal techniques, and demonstrate long-term efficacy in long term follow up studies.

Aspectos gerais e bucais da Síndrome de Marfan

Introdução: A Síndrome de Marfan é uma desordem genética que afeta o tecido conectivo. No contexto da Odontologia, poucos profissionais da área conhecem os sintomas da síndrome, bem como os cuidados necessários no atendimento ao paciente. Objetivo: O objetivo deste trabalho foi descrever as características anatômicas gerais e bucais de pessoas com Síndrome de Marfan. Material e método: Foram realizadas pesquisas nas bases de dados EBSCO, Bireme e Pubmed entre os anos de 2017 e 2018, sendo utilizados os seguintes descritores: Síndrome de Marfan AND Odontologia AND Manifestações bucais. Resultados: Foram localizados 13 artigos na base de dados BIREME, 23 no PubMed e cinco no EBSCO, totalizando 41 artigos. Desses, 10 foram selecionados para a realização desta pesquisa. As principais alterações gerais descritas na literatura incluem membros superiores e inferiores longos, pé chato, corpo fino com o segmento inferior maior que o segmento superior, aracnodactilia, peito plano com costelas proeminentes e escoliose, pectus carinatum, pectus excavatum, cifose, hiperextensibilidade, dolicostenomelia, alterações oculares e problemas cardíacos. As principais alterações bucais descritas incluem hipoplasia maxilar, retrognatia mandibular, macrostomia, dentição altamente apinhada com mordidas cruzadas anteriores e posteriores, palato de arco alto e relação molar classe II de Angle em ambos os lados e apresentam maior índice de doenças periodontais do que pacientes normais. Conclusões: Os principais cuidados que devem ser observados durante o tratamento odontológico relacionam-se a anamnese e ao exame clínico. O melhor entendimento dessa patologia poderá orientar decisões terapêuticas para prevenção e correção das desordens mencionadas neste trabalho. Descritores: Síndrome de Marfan; Odontologia; Manifestações Bucais. Referências Muñoz Sandoval J, Saldarriaga-Gil W, Isaza de Lourido C. Síndrome de Marfan, mutaciones nuevas y modificadoras del gen FBN1. 2014;27(2):206-15. García JLG, Cedeño LM, Medina JAG. Síndrome de Marfan. Medisan. 2007;11(4):1-5. Pfeiffer MET. Síndrome de Marfan em crianças e adolescentes: importância, critérios e limites para o exercício físico. Rev DERC. 2011;17(3):82-6. Lebreiro A, Martins E, Cruz C, Almeida J, Maciel MJ, Cardoso JC, et al. Síndrome de Marfan: manifestações clínicas, fisiopatologia e novas perspectivas da terapêutica farmacológica. Rev Port Cardiol. 2010; 29(6):1021-36. Velásquez C. Manejo odontológico integral en centro quirúrgico de un paciente con Sindrome de Marfan. Odontol Pediatr (Lima). 2015;14(1):80-5. Tsang AK, Taverne A, Holcombe T. Marfan syndrome: a review of the literature and case report. Spec Care Dentist. 2013;33(5):248-54. Bilodeau JE. Retreatment of a patient with Marfan syndrome and severe root resorption. Am J Orthod Dentofacial Orthop. 2010;137(1):123-34. Baraldi CEE, Paris MF, Robinson WM. A síndrome de Marfan e seus aspectos odontológicos: relato de caso e revisão da literatura. Rev Fac Odontol Porto Alegre. 2008;49(3):36-9. Sinha A, Kaur S, Raheel SA, Kaur K, Alshehri M, Kujan O. Oral manifestations of a rare variant of Marfan syndrome. Clin Case Rep. 2017;5(9):1429-34. Anuthama K, Prasad H, Ramani P, Premkumar P, Natesan A, Sherlin HJ. Genetic alterations in syndromes with oral manifestations. Dent Res J (Isfahan). 2013;10(6):713-22. Jain E, Pandrey RK. Marfan Syndrome. BMJ Case Rep. 2013;25(16):16-22. Staufenbiel I, Hauschild C, Kahl-Nieke B, Vahle-Hinz E, von Kodolitsch Y, Berner M, et al. Periodontal Conditions in patients with Marfan Syndrome: a multienter case conrol study. BMC Oral Health. 2013;13:59. Mallineni SK, Jayaraman J, Yiu CK, King NM. Concomitant occurrence of hypohyperdontia in a patient with Marfan syndrome: a review of the literature and report of a case. J Investig Clin Dent. 2012;3(4):253-57. Gott VL. Antoine Marfan and his syndrome: one hundred years later. Md Med J. 1998;47(5):247-52. Alves IC, Navarro F. Exercício fisico e sindrome de Marfan. Rev Bras Prescrição e Fisiologia do Exercício. 2008;2(8):149-57. Sivasankari T, Mathew P, Austin RD, Devi S. Marfan Syndrome. J Pharm Bioallied Sci. 2017;9(1):73-7. Sabbatini IF. Avaliação dos components anatômicos do sistema estomatognático de crianças com bruxismo, por meio de imagens obtidas por tomografia computadorizada cone beam [dissertação de Mestrado]. Ribeirão Preto: Universidade do Estado de São Paulo; 2012. Cistulli PA, Richards GN, Palmisano RG, Unger G, Berthon-Jones M, Sullivan CE. Influence of maxillary constriction on nasal resistance and sleep apnea severity in patients with Marfan's syndrome. Chest. 1996;110(5):1184-8.

1265 Severe Central and Obstructive Sleep Apnea in Teenager with Severe Obesity, Tonsillar Hyper-trophy, and Maxillary Constriction

Introduction Obesity in children escalated in the past 50 years. For American children 2-19 years old, Obesi-ty(BMI >= 95th%) increased from 5% in 1971-4 to 19%(13.7 million children)2015-16. Severe Obesity(BMI >=120th% or >35) is less common with prevalences of 1% 1971-4 to 6% in 2015-16(1). Obesity increases risk for physical and mental illness. Sleep apnea risk factors include obesity, maxillary restriction(3), and adenotonsillar hypertro-phy(4). Report of Case 16 yo boy with snoring, gasping during sleep, witnessed apneas, mouth breathing, morning head-aches, EDS, and learning disability requiring an IEP. Past medical history of neonatal snoring, apneas, and reflux. Physical exam revealed severe obesity(BMI 45.3), high arched/narrow palate, Class II bite, large tongue, Mallampati IV, Grade 3-4 tonsils, CricoMental Space +1cm. Inattentive with mildly de-pressed affect. No cardiovascular, pulmonary or neurologic findings. PSG: CAI 31.2, OAHI 23.8. Average O2 sat 97% with 11 minutes<88%. End-tidal CO2 average 50 during sleep and wake. 51% of total sleep time with ETCO2>50 mmHg. CPAP titration: CAI 1.8, OAHI 10.4. Average O2 sat 96% with <1 minute<88%. Events improved with CPAP 14 cm H20 to OAHI 3.5 with >30 minutes of supine REM. Conclusion Severe Central Sleep Apnea with significant obstructive component associated with hypoxia and hypoventilation. With the diurnal hypoventilation, the likely etiology for central apneas is Obesity Hypoventilation Syndrome(5). The central apnea improved with CPAP. His management included CPAP therapy, ENT referral for adenotonsillectomy(5), bariatric referral, and further evaluation for learning/behavior concerns. In retrospect, earlier diagnosis/intervention on behalf of this teenage boy with a history of neonatal snoring presenting now with Severe Obesity, tonsillar hypertrophy and maxillary constriction may have made a significant difference for his cognitive/mental/physical health outcomes.

Dental and Skeletal Changes after Transpalatal Distraction

Maxillary constriction is a common skeletal craniofacial abnormality, and transverse maxillary deficiency affects 30% of patients receiving orthodontic and surgical treatment. The aim of the study was to analyse craniofacial skeletal changes in adults with maxillary constriction after transpalatal distraction. The study group consisted of 36 patients (16 women) aged 17 to 42 years (M = 27.1; SD = 7.8) with a known complete skeletal crossbite and who underwent transpalatal distraction procedure. The measurements were obtained on diagnostic models, and cephalometric PA radiograms were obtained at time points, i.e., before treatment (T1) and after the completion of active distraction (T2). The analysis of diagnostic models involving the arch width measurement at different levels demonstrated a significant increase in L1, L2, L3, L4, L5, and L6 dimensions after transpalatal distraction. The largest width increase (9.5 mm) was observed for the L3 dimension (the intercanine distance). The analysis of frontal cephalograms displayed a significant increase in W1, W2, and W3 dimensions after transpalatal distraction. The largest width increase (4.9 mm) was observed for the W1 dimension at the level of the alveolar process of the maxilla. Transpalatal distraction is an effective treatment for transverse maxillary deficiency after the end of bone growth. The expansion observed on diagnostic models is close to a parallel segment shift mechanism, with a mild tendency towards a larger opening anteriorly. The maxillary segment rotation pattern analysed based on the frontal cephalograms is close to a hand fan unfolding with the rotation point at the frontonasal suture.

Does rapid maxillary expansion change natural head position in children with maxillary constriction? A systematic review and meta-analysis

Objetivo: uma revisão sistemática foi realizada para avaliar se a posição natural da cabeça (PNS) muda em crianças com constrição maxilar antes e após expansão rápida da maxila (ERM). Material e método: uma pesquisa foi realizada no MEDLINE via PubMeb, Scopus, Web of Science, LILACS, BBO e Cochrane Library sem restrições. Também foram pesquisadas a conferência anual dos resumos da IADR (1990–2017) e o registro de ensaios não publicados e em andamento. As dissertações e teses foram pesquisadas usando os bancos de dados ProQuest Dissertations e “Periódicos CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) de Teses”. Os estudos compararam a posição natural da cabeça em pacientes submetidos a expansão rápida da maxila (ERM) e pacientes não tratados, ambos com constrição maxilar. Resultados: um total de 3023 estudos foram identificados, três permaneceram em estudo qualitativo e todos esses estudos foram considerados de risco "pouco claro" de viés nos principais domínios. Apenas dois estudos apresentaram dados semelhantes para serem incluídos na meta-análise. Ambos os estudos avaliaram a posição natural da cabeça, através do ângulo entre a linha násio-sela e a vertical verdadeira (SN-Ver). As meta-análises demonstraram que, após 12 meses de acompanhamento, o ângulo SN-Ver diminuiu 3,39 graus (intervalo de confiança de 95% [IC] = 0,57 a 6,21; p = 0,02). Conclusão: o ERM promoveu aumento do ângulo SN-VER na criança após 12 meses de intervenção; no entanto, existem poucos estudos na literatura sobre esse tópico, e há necessidade de mais estudos bem delineados para investigar essa alteração.

Machine Learning in Orthodontics: Introducing a 3d Auto-segmentation and Auto-landmark Finder of Cbct Images To Assess Maxillary Constriction in Unilateral Impacted Canine patients

ABSTRACT Objectives To (1) introduce a novel machine learning method and (2) assess maxillary structure variation in unilateral canine impaction for advancing clinically viable information. Materials and Methods A machine learning algorithm utilizing Learning-based multi-source IntegratioN frameworK for Segmentation (LINKS) was used with cone-beam computed tomography (CBCT) images to quantify volumetric skeletal maxilla discrepancies of 30 study group (SG) patients with unilaterally impacted maxillary canines and 30 healthy control group (CG) subjects. Fully automatic segmentation was implemented for maxilla isolation, and maxillary volumetric and linear measurements were performed. Analysis of variance was used for statistical evaluation. Results Maxillary structure was successfully auto-segmented, with an average dice ratio of 0.80 for three-dimensional image segmentations and a minimal mean difference of two voxels on the midsagittal plane for digitized landmarks between the manually identified and the machine learning–based (LINKS) methods. No significant difference in bone volume was found between impaction ([2.37 ± 0.34] 104 mm3) and nonimpaction ([2.36 ± 0.35] 104 mm3) sides of SG. The SG maxillae had significantly smaller volumes, widths, heights, and depths (P < .05) than CG. Conclusions The data suggest that palatal expansion could be beneficial for those with unilateral canine impaction, as underdevelopment of the maxilla often accompanies that condition in the early teen years. Fast and efficient CBCT image segmentation will allow large clinical data sets to be analyzed effectively.