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Cbc teval of exp -compressed Cbc teval of exp -compressed Presentation Transcript

  • THE EDWARD H. ANGLE SOCIETY OF ORTHODONTISTS Midwest Component Annual Meeting Orlando, Florida January 29 th _ February 2 nd 2011
  • CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC MAXILLARY SINUS CHANGES ASSOCIATED WITH TWO TYPES OF MAXILLARY EXPANDERS Valmy Pangrazio-Kulbersh, DDS, MS
  • CONTRIBUTORS
    • Dr. Paul Wine
    • Dr. Richard Kaczinski
    • Dr. Mariana Haughey
  • CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH TWO TYPES OF MAXILLARY EXPANDERS
    • INTRODUCTION
    • “ In dento-facial orthopedics the transverse dimension seems to be the most important, since with facial growth the width dimension changes the least; it also stops growing the earliest”
    • -A.J. Haas, DDS, MS
    • 1980
    Haas AJ. Long term Post treatment Evaluation of Rapid Palatal Expansion. Angle Orthod. 1980;50:189-217. INTRODUCTION
    • Widening of the dental arches using orthopedic force first reported in 1860 by Emerson H. Angell 11
    • 1860-1958  Widespread opposition to maxillary expansion due to instability
        • Angle (1910)-Arch wires “Physiologic Expansion”
        • Tweed (1945)-Extraction
    . INTRODUCTION
    • Hass- 1959(experimental), 1961(clinical) 2-4
        • Midpalatal suture is opened during RPE, but also became re ossified within 90 days post expansion
        • The procedure is relatively pain free
        • Mandibular teeth uprighted/expanded
        • Internasal width increased
    HISTORY
    • Melsen (1975) 11
        • Age related palatal growth changes
        • Interdigitation of the mid-palatal suture increases with age
    • Krebs (1964) 25 , Wertz (1970) 26 , Hicks (1978) 28
        • Suture opens in a triangular pattern
    . . INTRODUCTION
    • Rapid Maxillary Expanders 1-7,11
    • Increase transverse width of the maxilla
    • Correction of Cross bites
    • Addition of Arch Length
    • Correction of Axial Inclinations of the Posterior Teeth
    • Broadening the Smile
    INTRODUCTION
    • Preparation for Functional Jaw Orthopedics or Orthognathic Surgery
    • Mobilization of the Maxillary Sutural System
    • Reduction in Nasal Resistance
    • Improvement of Breathing
    INTRODUCTION
    • Side Effects of RPE 1,12,13
    • Dental extrusion
    • Lateral rotations of the maxillary segments
    • Bite opening
    • Dental tipping
    • Alveolar bending
    • Gingival recession
    INTRODUCTION
    • Skeletal Effects 4,7,8
    • Sutural changes
      • Widening of the nasal cavity
      • Subsequent soft tissue changes
      • Remodeling of the maxillary sinus
    INTRODUCTION
    • Widening of the nasal cavity
    . INTRODUCTION
  • . INTRODUCTION
    • Bonded Hyrax RPE 14-16
    • Tooth-borne in origin
    • Posterior segments covered by acrylic pads
    • Metal substructure and jackscrew
    • Most commonly used in patients with vertical dimension irregularities
    INTRODUCTION
    • Banded Hyrax RPE 1-7,17
    • Tooth-borne in origin
    • Orthodontic bands on 1 st molar and 1 st premolars
    • Mini-Hyrax only bands on 1 st molars
    • Metal substructure with jack screw
    • More hygienic and comfortable then other expansion appliances
    INTRODUCTION
    • Previous Research 8,18,19,20
    • Dental Casts
    • Two dimensional postero-anterior cephalograms
    • Occlusal radiographs
    • High radiation CT scans-Linear measurements
    INTRODUCTION
    • Cone Beam Computed Tomography (CBCT)
    • Evaluate craniofacial structures in three dimensions with minimal distortion
    • Lower radiation doses than conventional CT scans 22
    INTRODUCTION
    • The purpose of this study was to assess three dimensionally, with the aid of ICat technology, the maxillary skeletal, dental, soft tissue, and volumetric airway changes associated with the banded versus the bonded hyrax expanders.
    INTRODUCTION
  • CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH TWO TYPES OF MAXILLARY EXPANDERS
    • METHODS AND MATERIALS
  • METHODS AND MATERIALS
    • Inclusion Criteria
      • Constricted maxillary arch with or without cross-bites
      • Full permanent dentition
      • Absence of fluid accumulation in the maxillary sinus
    METHODS AND MATERIALS
    • Expansion Protocol
      • 1 turn per day for 4-6 weeks
      • 6-10mm of activation
      • Expanders left in for 6 months as retention
      • T1: Pretreatment CBCT scan
      • T2: Immediately after expansion appliance removal (6 months post tx)
    METHODS AND MATERIALS
    • Sagittal Plane Coronal plane Axial plane
    METHODS AND MATERIALS
  • Palatal Maxillary Width (mm) PMW METHODS AND MATERIALS
  • Buccal Maxillary Width (mm) BMW METHODS AND MATERIALS
  • Palatal CEJ to X (˚) PCEJ-X METHODS AND MATERIALS
  • Buccal CEJ to X (˚) BCEJ-X METHODS AND MATERIALS
  • Buccal Cusp Tip to X (˚) BCusp-X METHODS AND MATERIALS
  • Posterior Nasal Width (mm) PNW P METHODS AND MATERIALS
  • Nasal Floor Width (mm) NFW METHODS AND MATERIALS
  • Anterior Nasal Width (mm) NWH/NWL P NWH NWL METHODS AND MATERIALS
  • Maxillary Width (mm) MaxW METHODS AND MATERIALS
  • Alar Width (mm) METHODS AND MATERIALS
  • Maxillary Sinus Volume (mm³) MSV METHODS AND MATERIALS
  • METHODS AND MATERIALS Posterior airway Volume (mm³) PAV
    • Statistical Analysis
      • To test for differences in how the two samples change over time, mixed design analysis of variance (ANOVA) was done with both between-subjects (bonded vs. banded) and within subjects (time) effects
      • Post hoc t tests were used to determine individual differences
    METHODS AND MATERIALS
  • CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH TWO TYPES OF MAXILLARY EXPANDERS
    • RESULTS
    • Palatal Maxillary Width – Canine (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 16.369 18.977 2.608 <.001 * within group Bonded 13.78 15.99 2.21 <.001 * within group Sig at start NS 0.398 0.423 Interaction effects
    • Palatal Maxillary Width – 1 st Premolar (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 20.869 23.32 2.451 <.001 * within group Bonded 17.67 19.57 1.9 <.001 * within group Sig at start NS 0.551 0.297 Interaction effects
    • Palatal Maxillary Width – 2nd Premolar (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 24.162 26.8 2.638 <.001 * within group Bonded 20.5 22.35 1.85 <.001 * within group Sig at start * 0.788 0.100 Interaction effects
    • Palatal Maxillary Width – 1 st Molar (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 26.638 29.838 3.2 <.001 * within group Bonded 22.03 23.81 1.78 <.001 * within group Sig at start * 1.42 0.002 * Interaction effects
  • RESULTS
    • Buccal Maxillary Width – Canine (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 31.45 33.423 1.973 <.001 * within group Bonded 24.98 26.61 1.63 <.001 * within group Sig at start * 0.343 0.473 Interaction effects
    • Buccal Maxillary Width – 1 st Premolar (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 38.085 41.108 3.023 <.001 * within group Bonded 30.64 32.94 2.3 <.001 * within group Sig at start * 0.723 0.314 Interaction effects
    • Buccal Maxillary Width – 2nd Premolar (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 44.131 47.162 3.031 <.001 * within group Bonded 35.32 37.76 2.44 <.001 * within group Sig at start * 0.591 0.331 Interaction effects
    • Buccal Maxillary Width – 1 st Molar (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 50.95 55.28 4.33 <.001 * within group Bonded 40.39 43.25 2.86 <.001 * within group Sig at start * 1.47 0.018 Interaction effects
  • RESULTS
    • Palatal CEJ Angulation (˚)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 25.28 28.36 3.09 <.001 * within group Bonded 25.21 26.9 1.69 <.001 * within group Sig at start NS 1.40 0.003 * Interaction effects
    • Buccal CEJ Angulation (˚)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 41.09 44.30 3.22 <.001 * within group Bonded 40.95 42.31 1.36 <.001 * within group Sig at start NS 1.86 0.001 * Interaction effects
    • Buccal Cusp Angulation (˚ )
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 37.315 41.31 3.99 <.001 * within group Bonded 37.08 38.1 1.02 <.001 * within group Sig at start NS 2.97 <.001 * Interaction effects
    • Maxillary Width (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 58.86 61.45 2.58 <.001 * within group Bonded 47.68 49.66 1.98 <.001 * within group Sig at start * 0.60 0.19 Interaction effects
    • Posterior Nasal Width (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 27.36 29.65 2.92 <.001 * within group Bonded 21.53 23.18 1.65 <.001 * within group Sig at start * 0.64 0.072 Interaction effects
    • Nasal Floor Width (mm)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 23.462 25.62 2.15 <.001 * within group Bonded 18.84 20.86 2.02 <.001 * within group Sig at start * 0.13 0.776 Interaction effects
    • Anterior Nasal Width High (mm)
    * P≤.05 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 22.80 23.61 0.81 0.14 within group Bonded 22.59 24.03 1.44 0.01 * within group Sig at start NS -0.63 0.37 Interaction effects
    • Anterior Nasal Width Low (mm)
    * P≤.05 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 16.28 17.71 1.43 0.02 * within group Bonded 16.48 17.84 1.36 0.008 * within group Sig at start NS 0.07 0.92 Interaction effects
    • Alar Width (mm)
    * P≤.05 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 34.72 36.06 1.34 0.006 * within group Bonded 36.00 37.24 1.24 0.048 * within group Sig at start NS 0.10 0.88 Interaction effects
    • Maxillary Sinus Volume (mm³)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 21796.4 24352.3 2582.9 <.001 * within group Bonded 27674.8 29412.1 1737.3 <.001 * within group Sig at start NS 845.6 NS Interaction effects
    • Posterior Airway Volume (mm³)
    * P≤.003 RESULTS T1 T2 T1 to T2 Significance Change over time Banded 11858.9 19277.9 -7418.6 NS within group Bonded 11518.7 11423.6 95.1 NS within group Sig at start NS 340,2 NS Interaction effects
  • CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC MAXILLARY SINUS CHANGES ASSOCIATED WITH TWO TYPES OF MAXILLARY EXPANDERS
    • DISCUSSION
    • Dental Tipping
      • Multiple studies 7,13,25 show that a decrease in sutural opening can lead to dental tipping and alveolar bending
      • Garrett et al 1 showed alveolar bending accounted for 13% of expansion at the 1 st molar compared to 6% at the 1 st premolar due a decrease in sutural opening.
      • Hicks 28 showed that maxillary expansion produces close to 50% skeletal movement and 50% dental tipping.
    DISCUSSION
      • Wertz 26 verified the maxillary suture had a nonparallel opening during separation in a 3 to 1 ratio from anterior to posterior.
        • Interlocking pyramidal process of the palatine bone
        • Immobilization of the medial and lateral pterygoid plates of the sphenoid bone
      • Age was the major contributing factor to prevention of sutural opening
    DISCUSSION
      • The results obtained from this ICAT three dimensional study was similar to previous research that demonstrated that sutural opening in a triangular pattern with the wide base at the anterior portion of the maxilla
      • The current study showed significant differences of first molar tipping between banded and bonded expanders
      • More palatal alveolar bending was seen in the banded expander possibly due to dental tipping
    DISCUSSION
  • Vanarsdall, Herberger TA: rapid palatal expansion:Long term stability and periodontal implication, unpublished thesis, Philadelphia 1987, university of Pennsylvania
    • 55 pacients .
    • 8 - 13 years old.
    • Evaluated 8 to 10 years after expansion.
    • Expansion 10 a 10.5 mm in approx. 3 weeks.
    • Compared to 30 controls.
  • Showed that thinning of the buccal alveolar bone and increase in width of the lingual alveolar was more prominent with the Hass type of expander vs. the hyrax type. Daniela Gamba Gaig, Jose fernando castanha Henriques, Guillerme janson, Marco roberto Freitas, Adriano Yacubian Fernandez. Periodontal effects of rapid maxillary expansion with tooth tissue borne appliance and tooth borne expanders a computed tomography evaluation. Am J Orthod dentofacial orthop 2006;129:749-758
  • Daniela Gamba Gaig, Jose fernando castanha Henriques, Guillerme janson, Marco roberto Freitas, Adriano Yacubian fernandez. Periodontal effects of rapid maxillary expansion with tooth tissue borne appliance and tooth borne expanders a computed tomography evaluation. Am J Orthod dentofacial orthop 2006;129:749-758
    • expansores inducen pérdida de las paredes bucales de los dientes de
    • anclaje especialmente en personas que las tienen finas.
    • a nivel de premolares los expansores anclados solamente a dientes
    • producen mas pérdida ósea que los expansores anclados a tejidos y
    • dientes.
  • DISCUSSION
      • This difference may be due to the appliance design.
        • bonded expander is cemented to all posterior teeth with acrylic, dissipating forces
        • Banded expanders have bands on the first molars and premolars. These teeth must bear all the force exerted by the palatal expander.
    DISCUSSION
        • Since it is more difficult to expand the posterior maxilla, it is not surprising that we see significant tipping of the first molar using a banded expander.
    DISCUSSION
    • Naso-maxillary Complex
      • Both appliances were equally successful in increasing anterior/posterior nasal width, nasal floor width, maxillary width, nasal soft tissue, and maxillary sinus volume
      • An increase in nasal width and maxillary sinus volume can have significant effects on nasal respiration, nasal resistance, and soft tissue nasal changes 4,10,29
    DISCUSSION
      • Haas 4 showed that by widening the maxilla, widening of the nose occurred as well as increased nasal respiration in chronic mouth breathers.
      • Berger et al. 10 used photographic analysis to show soft tissue changes associated with maxillary expansion .
      • Garrett et al. 1 showed a decrease in linear dimension of the maxillary sinus due to an increase width of the nasal cavity.
    DISCUSSION
      • The current study suggests that skeletal width increases have a near 1:1 ratio with soft tissue increases after expansion
    DISCUSSION
      • No previous studies have related anterior to posterior nasal bony changes which is now possible due to CBCT imaging.
        • Expansion produces not only posterior, but anterior nasal widening leading to subsequent soft tissue changes.
      • No current studies analyze three dimensional changes in the maxillary sinus and posterior airway after maxillary expansion
        • The increase in maxillary sinus volume can possibly improve nasal respiration, decrease nasal resistance, and increase airway reservoirs. Although there was an increase in posterior airway volume, the results were not significant possibly due to the large standard deviations observed.
    DISCUSSION
      • In the future, CBCT imaging and volumetric software can be used to look at the entire naso-maxillary complex
    DISCUSSION
  • CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH TWO TYPES OF MAXILLARY EXPANDERS
    • CONCLUSIONS
    • CBCT can be used reliably to assess skeletal and dental changes associated with rapid palatal expansion.
    • Both expanders increased the transverse dimension of the skeletal and soft tissue naso-maxillary complex equally. However, more dental tipping was observed with the banded expander.
    • Maxillary sinus volume increased between 6-11% after expansion but the posterior airway volume change was not significant.
    CONCLUSIONS
  • WHERE DO WE GO FROM HERE?
  • INITIAL 14 años 2 meses CVM 4
  •  
  •  
  • 1/9/07 EXPANSION COMPLETED 1 vuelta por día durante 1 mes 15 días Expansion obtenida 12mm
  • 10/2/07 (5 MONTHS OF PROTRACTION) Periodo de retención 5 meses
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  •  
  • 3/18/08 Tiempo de tratamiento 22 meses
  •  
  • Sean meadows 4/15/08
  •  
  • Un mes de posisionador y ajuste oclusal
  •  
  •  
  • WORKS CITED
  • WORKS CITED
  •  
  •