Dental Press Jounal of Orthodontics
Dental Press International

v. 18, no. 5

Dental Press Journal of Orthodontics – ISSN 2176-9451

Dental Press J. Orthod.

v. 18, no. 5

September / October

2013


Editorial

From embryo to maturity
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"Time and destiny have had a lifetime relationship, they are a bond, a pair." (Nilson Chaves)

In this issue, Dental Press Journal of Orthodontics (DPJO) celebrates 18 years of a meaningful existence. We are able to salute our readers with the deep conviction that we have come this far because we took strategically planned paths which could not be described on the 180 pages that comprise the theme of this volume: ?Orthodontic treatment in adults.?

When we celebrate dates, especially those that complete a cycle, we tend to relive the past and devise plans for the future. For a periodical that began its embryogenesis with the publication of translated articles, publishing original articles would already be a significant change. A rapid progress that makes us recall a new-born baby who ceases to express his desires by means of facial expressions ? which are simulated by mothers and grandmothers ? and begins saying his first words, emphasizing his first wishes by his own appropriate words.

The steps are firm and the run is inexorable for those who dream about flying even higher. At the age of 10, DPJO was indexed on SciELO1 (a very renowned bibliographic database) which allowed us to become part of a select group of journals that are qualified according to the Brazilian Coordination for Improvement of Higher Education Personnel (CAPES). In fact, we are still the only Brazilian dental journal to be recognized with this merit. We would like to take the opportunity to express our desire for company.

On the verge of adolescence, at the age of 13, we stepped into computerization, gaining its organizational benefits. Articles begin to be submitted exclusively online,2 which facilitates for authors, reviewers, editors and other staff members. At the peak of our growth, the number of submissions now bursts and the young periodical learns how to say no: the solicitous child now welcomes the adolescent who rejects things more than accepts them ? a true adolescence. The expression of his needs is underlined by a high frequency of rejections, which arouses undesirable trouble. However, such trouble is extremely necessary for the adolescent to mature and focus on the objectives set since his intrauterine phase.

Growth takes a different turn when the scientific articles previously published in the language of Camões begin to be published in the universal language of science ? the language of Shakespeare, who was contemporary with Camões.3 And that was an inherent change for those who wish to spread the magnitude of Brazilian Orthodontics to a larger number of ears and eyes. We did not change our language, we simply had to express ourselves in another one. DPJO, consolidated by its importance within clinical Orthodontics, has kept and shall keep a mirror of its publications in Brazilian Portuguese. It is all about thanking for the credibility given to us by those who believed in our potentiality when we were still scared of the uncertainties and fears of childhood.

Our speech is consolidated in two different languages ? among stumbles that are common to effusive adolescent learners. Legs and arms are extended due to a physiological need to sustain a hebiatric skeleton. These extensions reach institutions that share similar purposes: to raise Brazilian Orthodontics to its incontestable prominent position. At the age of 17, Dental Press Journal of Orthodontics became the official publication in charge of disclosing news about the Brazilian Dental Association (ABOR)4 and the Brazilian Board of Orthodontics and Dentofacial Orthopedics. In 2013, it began to publish the abstracts of studies presented during the Meeting of the Brazilian Group of Professors of Orthodontics and Pediatric Dentistry ? a major achievement that contributes to improving the postgraduate scientific production in Brazil. 

In 2012, on the verge of turning 18 years old, articles? citations, which were already going through a process of development, duplicated. In 2013, we gained the recognition of the most important international database on health sciences (PubMed),5 which shall significantly increase the scientific impact of this periodical. These last achievements reveal the dawn of maturity. Now, that we are able to follow our own path in a swifter manner, it becomes necessary to reassess our plans. For the next year, our aims include duplicating our scientific impact and improving our CAPES evaluation criteria. Additionally, we aim at reducing the time between submission and publication. However, we understand that our aims are only the reflection of a work strongly connected to the conviction that we have been able to achieve maturity at the age of 18 because the eyes of those who read these last words believed in the brave view of those who gave birth to this periodical. Yes, we do have a father and a mother.


David Normando - editor-in-chief 

(davidnormando@hotmail.com)

Orthodontics Highlights

Orthodontic Insight

Clarifications, guidelines and questions about the dental leaching ?associated? with orthodontic treatment

Teeth whitening. Dental bleaching. Orthodontic treatment.

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With regard to the best moment for carrying out or recommending dental bleaching to orthodontic patients, some explanations and orientations are given in order to answers the following questions: 1) Why orthodontic treatment completion is considered the best opportunity for carrying out the procedure? 2) Why dental bleaching should not be performed immediately before orthodontic treatment? 3) If that would be possible at any special case, what would that be? 4) Why dental bleaching should not be performed during orthodontic treatment? 5) If that would be possible at any special case, what would that be? This article highlights why it is essential to protect both the mucosa and the cervical region, regardless of the moment when dental bleaching is performed, whether associated with orthodontic treatment or not. The ?how?, ?why? and ?if? of whether or not it is convenient to perform dental bleaching before orthodontic treatment are still a matter of clinical suggestion, as it is a procedure that is under analysis, empirical knowledge waiting for scientific proof or disproof! Although tooth enamel has adamantine fluid flowing within it, providing a specific metabolism that is peculiar to its own and which could scientifically explain and base the option of carrying out teeth whitening before and during orthodontic treatment, we must still be very careful. 

Evidence-based Orthodontics

Evidence-based Orthodontics: Has it something to do with your patient?
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This section will be led in order to provide the clinician with support for comprehension and critical analysis of scientific articles, with elucidation of the main types of scientific studies, specific methodology and statistical analysis for clinical practice based in scientific evidence. The objective is to approximate clinician and science, easing the comprehension of the intricate scientific methods. 

[...]

Interview

An interview with Adilson Luiz Ramos
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»Graduated in Dentistry, School of Dentistry - Bauru / University of São Paulo (USP) (1998).

»Resident in Orthodontics at the Hospital for Rehabilitation of Craniofacial Anomalies/ University of São Paulo (USP) (1989-1992).

»MSc in Orthodontics, College of Dentistry of Bauru/USP (1995).

»PhD in Dentistry (Orthodontics) College of Dentistry of Araraquara / State University of São Paulo (UNESP) (2001).

»Associate Professor at the State University of Maringá (UEM).

»Former Coordinator of the Post-Graduation program in Integrated Dentistry at the State University of Maringá (UEM), from 2008 to 2011.

»Former editor of Dental Press Journal of Orthodontics, from 2003 to 2006.

A long-standing friend. Twenty years ago, we started the Orthodontics program at the State University of Maringá, and I am still surprised by his huge cultural background, his ability to deal with problems and his endless concerns to avoid hurting people?s feelings. Our students say that he knows everything from Quantum Physics to Statistics, from Microbiology to Physiology, from Bossa Nova to iPhones and iPads.

He was the editor of Dental Press Journal of Orthodontics between 2003 and 2006, and during this period, the periodical was indexed in SciELO, Scientific Electronic Library Online (FAPESP? Research Support Foundation of the State of São Paulo). We will be eternally thankful for his dedication which was essential to consolidate the periodical in an international scenario. He is a perfectionist orthodontist who has got a huge number of adult patients under multidisciplinary treatment. A researcher who carefully designs his works and advises his students. A professor who is greatly admired by his students and colleagues. A reference for any professor working at our institution. A passionate husband and a father who is absolutely dedicated to his two beautiful daughters. A friend for a lifetime.


Laurindo Furquim

Original Article

Assessment of pain experience in adults and children after bracket bonding and initial archwire insertion

Pain. Orthodontic treatment. Visual Analog Scale.

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Introduction: Ninety five percent of orthodontic patients routinely report pain, due to alterations in the periodontal ligament and surrounding soft tissues, with intensity and prevalence varying according to age. 

Objective: This study aimed to assess toothache and buccal mucosal pain in adults and children during two initial phases of the orthodontic treatment. 

Methods: The intensity of toothache and buccal mucosal pain reported by 20 patients, 10 children (11-13 years) and 10 adults (18-37 years) was recorded with the aid of a Visual Analog Scale (VAS), during 14 days ? 7 days with bonded brackets only and 7 days with the initial archwire inserted. 

Results: There was no significant difference in pain intensity among adults and children. After bracket bonding, 50% of the children and 70% of the adults reported pain. 70% of both groups reported pain after initial archwire insertion. While adults reported constant, low intensity, buccal mucosal pain, the children showed great variation of pain intensity, but with a trend towards decreasing pain during the assessment period. After initial archwire insertion the peaks of toothache intensity and prevalence occurred 24 hours in children and 48 hours in adults. 

Conclusions: In general, children reported pain less frequently than adults did, though with greater intensity. 

Class II malocclusion treatment with the Herbst appliance in patients after the growth peak

Angle Class II malocclusion. Head circumference. Functional orthodontic appliance.

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Objective: The objective of this study was to evaluate dentoskeletal effects in the treatment of Class II malocclusion performed with the Herbst appliance in patients at post-peak stage of growth.

Methods: The sample consisted of 16 patients with Class II malocclusion and average initial and final ages of 14.04 (ranging from 11.50 to 35.66) and 17.14 (ranging from 13.68 to 38.64) years, respectively, who were treated for an mean time of 2.52 years. Lateral cephalograms were obtained at treatment onset (T1) and completion (T2) to evaluate the effects of therapy. Initial dental casts were also used to evaluate the overjet and the anteroposterior severity of molar relationship at treatment onset. The cephalometric changes between initial and final stages were compared by means of the non-parametric Wilcoxon test.

Results: The results showed that the Herbst appliance did not promote significant changes in the maxillary component and the effective length of the mandible significantly increased without improving the maxillomandibular relationship. Changes in the maxillary and mandibular dentoalveolar components revealed that the maxillary incisors exhibited retrusion and lingual tipping, while the mandibular incisors presented increased protrusion and buccal tipping. The dental relationships exhibited significant improvements with the treatment.


Conclusion: Based on the present results, it was concluded that the effects of treatment performed with the Herbst appliance in patients at post-peak stage of growth are predominantly of dentoalveolar nature.

Effects of mandibular protraction appliance associated to fixed appliance in adults

Angle Class II Malocclusion. Functional orthodontic appliances. Mandibular advancement. Adult.

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Objective: This retrospective study aimed to conduct a cephalometric evaluation of the skeletal, dental and soft tissue effects resulting from treatment of adult patients presenting Class II malocclusion, performed with a Mandibular Protraction Appliance (MPA) combined with a fixed orthodontic appliance.

Methods: The sample consisted of teleradiographs obtained before and after treatment of 9 adult patients (initial mean age of 22.48 years) with bilateral Class II, division 1, malocclusion. Paired t test (p < 0.05) was applied to compare initial and final values.

Results: t test revealed an increase in anteroinferior facial height and posterior facial height. The dental changes include: extrusion of upper incisors, buccal inclination, protrusion of lower incisors, mesialization and extrusion of mandibular molars. Regarding the soft tissue component, there was an increase in nasolabial angle in addition to upper lip retrusion.


Conclusions: The effects of treating Class II malocclusion adult patients, by means of using Mandibular Protraction Appliance (MPA) combined with a fixed appliance were mostly observed in the mandibular arch, and consisted of buccal inclination, protrusion and intrusion of incisors, and mesialization and extrusion of the molars.

Cephalometric evaluation of the predictability of bimaxillary surgical-orthodontic treatment outcomes in long face pattern patients: A retrospective study

Corrective orthodontics. Predictive value of tests. Oral surgery. Face.

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Objective: The aim of this study was to compare by means of McNamara as well as Legan and Burstone?s cephalometric analyses, both manual and digitized (by Dentofacial Planner Plus and Dolphin Image software) prediction tracings to post-surgical results.

Methods: Pre and post-surgical teleradiographs (6 months) of 25 long face patients subjected to combined orthognathic surgery were selected. Manual and computerized prediction tracings of each patient were performed and cephalometrically compared to post-surgical outcomes. This protocol was repeated in order to evaluate the method error and statistical evaluation was conducted by means of analysis of variance and Tukey?s test.

Results: A higher frequency of cephalometric variables, which were not statistically different from the actual post-surgical results for the manual method, was observed. It was followed by DFPlus and Dolphin software; in which similar cephalometric values for most variables were observed.


Conclusion: It was concluded that the manual method seemed more reliable, although the predictability of the evaluated methods (computerized and manual) proved to be reasonably satisfactory and similar. 

Factors related to orthodontic treatment time in adult patients

Adult. Time factors. Orthodontics.

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Introduction: The length of time that it takes an orthodontist to treat adult patients varies widely. 

Objective: The aim of this study was to investigate how different variables influence treatment time. 

Methods: Seventy clinical case reports of successfully treated adult patients were examined. The patients were selected from 4,723 records held by three experienced orthodontists. The influence exerted by the following variables on treatment time was assessed: age, sex, facial pattern, severity of malocclusion (measured by the PAR index), sagittal relationship of canines, type of brackets (ceramic or metal), tooth extractions, missed appointments and orthodontic appliance issues/breakages, the latter being the dependent variable. Assessment was performed by multiple linear regression analysis, followed by the stepwise method with p < 0.05. 

Results: The number of times a patient missed their appointment (no-show) (R2 = 14.4%, p < 0.0001) and the number of appliance issues/breakages (R2 = 29.71%, p = 0.0037) significantly affected variability in treatment time, and these two variables together can predict 43.75% (R2 total) of the overall variability in treatment time. Other factors, such as canine relationship at the beginning of treatment, bracket type (metal or ceramic), tooth extractions, age at start of treatment, severity of the initial malocclusion, sex and facial pattern had no significant bearing on treatment time. 

Conclusions: The duration of orthodontic treatment in adults, when performed by experienced orthodontists, is mainly influenced by factors related to patient compliance. However, several factors which were not included in this study may contribute to variability in orthodontic treatment time. 

Effects of chin advancement surgery in hyoid bone and tongue positions and in the dimension of the oropharynx

Orthognathic surgery. Chin. Oropharynx. Hyoid bone. Tongue.

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Introduction: Advancement genioplasty has been increasingly indicated for the correction of anterior mandibular deficiency as it balances the patient?s profile and generates functional changes. 

Objective: Thus, the aim of this study was to assess the effects of advancement genioplasty in the oropharyngeal size and in the position of the hyoid bone and tongue.

Methods: The sample comprised 22 lateral cephalometric radiographs of 11 individuals who had undergone advancement genioplasty alone. Eleven of these radiographs depicted the immediate preoperative period (T0) and the other 11 the postoperative period after at least four months (T1). The radiographs were scanned and exported to the Radiocef Studio 2.0® software (Radio Memory Ltda., Belo Horizonte, MG, Brazil). The landmarks were then identified and automatically measured by the program.

Results: The results showed statistically significant differences between the horizontal position of the hyoid bone and tongue and in the oropharyngeal size. The hyoid bone and tongue were repositioned anteriorly after surgery (p = 0.01), thereby increasing the dimension of the oropharyngeal airspace (p = 0.01).

Conclusions: The oropharyngeal dimension increased as the tongue base and hyoid bone were repositioned more anteriorly. 

Auditory characteristics of individuals with temporomandibular dysfunctions and dentofacial deformities

Temporomandibular joint disorders. Hearing disorders. Audiometry. Malocclusion.

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Objective: To investigate whether there is any relationship between otological as well as vestibular symptoms, audiological findings and type of temporomandibular disorder (articular, muscular and mixed); and to check the distribution of the temporomandibular disorders (TMD) dysfunction degree in the research population.

Methods: A retrospective study involving 30 patients of both sexes, aged between 18 and 49 years old, diagnosed with TMD and dentofacial deformities, who were subject to clinical evaluation (muscle palpation, auscultation of temporomandibular joint during mandibular motion and measurement of jaw movement), audiological testing (pure tone audiometry and immittance testing) and two questionnaires, one on otological and vestibular symptoms and the other on TMD anamnesis. Based on both the anamnesis questionnaire and the clinical assessment, the subjects were divided according to the type and degree of TMD dysfunction (mild, moderate and severe), and compared regarding the occurrence of auditory signs and symptoms, vestibular symptoms and audiological findings according to TMD type.

Results: The anamnesis questionnaire demonstrated higher prevalence (83.33%) of severe TMD. Subjects with mixed TMD had more complaints about hypoacusis than those with muscular TMD (p < 0.05). The results showed no change in either audiological and immittance testing for all assessed individuals.

Conclusion: Otological symptoms are present in subjects with TMD and dentofacial deformities, regardless of the classification of TMD (articular, muscular or mixed). Those with mixed TMD may have higher incidence of complaints about hypoacusis than subjects with muscular TMD. Further studies are needed to investigate the relationship between otological symptoms and the different types of TMD.

Is there correlation between alveolar and systemic bone density?

Bone density. Dental radiography. Densitometry.

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Objective: The present study assessed the correlation between maxillomandibular alveolar bone density and systemic bone mineral density (BMD). 

Methods: Dual-energy X-ray absorptiometry of the anterior and posterior maxillomandibular alveolar bone, of the standard sites for the measurement of BMD (lumbar spine and femur) and the third cervical vertebra was performed on 23 middle-aged women. Periapical radiographs were also obtained, with an aluminum step-wedge as reference for the digital reading of apical bone density of the upper incisors.

Results: Spearman?s correlations coefficients revealed that density in the apical region was correlated with that of the femoral neck (r = 0.433; p < 0.05); BMDs of the posterior regions of the mandible and maxilla were significantly correlated with that of the cervical vertebra (r = 0.554, p ? 0.01 and r = 0.423, p ? 0.05, respectively); and the anterior maxilla was correlated with the posterior mandible (r = 0.488, p ? 0.05). 

Conclusion: Bone density of the maxillary alveolar bone was significantly correlated with that of the femoral neck. Among the bone densities of the alveolar regions, only the anterior maxilla and the posterior mandible were significantly correlated. The findings suggested that bone densitometry might be individually and locally evaluated. 

Horizontal and vertical maxillary osteotomy stability, in cleft lip and palate patients, using allogeneic bone graft

Orthognathic surgery. Oral surgery. Bone grafting.

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Objective: This study was carried out to evaluate maxillary stability after orthodontic-surgical treatment of patients with cleft lip and palate. Cephalometric analysis was applied to two different groups, with and without allogeneic bone graft.

Methods: The sample comprised 48 patients with cleft lip and palate. The test group comprised 25 patients who, after correction of maxillary position, received allogeneic bone graft at the gap created by Le Fort I osteotomy. The control group comprised 23 patients and its surgical procedures were similar to those applied to the test group, except for the use of bone graft. Manual cephalometric analysis and comparison between lateral teleradiographs, obtained at the preoperative phase, immediate postoperative phase and after a minimum period of six months, were carried out.

Results: An higher horizontal relapse was observed in the control group (p<0.05). There were no statistically significant differences in vertical relapses between test and control groups (p>0.05).

Conclusion: The use of allogeneic bone graft in cleft lip and palate patients submitted to Le Fort I osteotomy contributed to increase postoperative stability when compared to surgeries without bone graft.

Comparison of the changes of alveolar bone thickness in maxillary incisor area in extraction and non-extraction cases: Computerized tomography evaluation

Alveolar ridge. Tooth movement. Tooth extraction. Tomography.

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Objective: To compare, through computed tomography, alveolar bone thickness changes at the maxillary incisors area during orthodontic treatment with and without tooth extraction.

Methods: Twelve patients were evaluated. They were divided into 2 groups: G1 - 6 patients treated with extraction of right and left maxillary first premolars, with mean initial age of 15.83 years and mean treatment length of 2.53 years; G2 - 6 patients treated without extraction, with mean initial age of 18.26 years and mean treatment length of 2.39 years. Computed tomographies, lateral cephalograms and periapical radiographs were used at the beginning of the treatment (T1) and 18 months after the treatment had started (T2). extraction Space closure occurred in the extraction cases. Intragroup and intergroup comparisons were performed by dependent and independent t test, respectively. 

Results: In G1, the central incisor was retracted and uprighted, while in G2 this tooth showed vestibularization. Additionally, G1 presented a higher increase of labial alveolar bone thickness at the cervical third in comparison with G2. The incidence of root resorption did not present significant differences between groups. 

Conclusion: There were no changes in alveolar bone thickness when extraction and nonextraction cases were compared, except for the labial alveolar bone thickness at the cervical third of maxillary incisors.

Evaluation of life quality of patients submitted to orthognathic surgery

Quality of life. Oral surgery. Orthodontics.

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Objective: To compare changes related to self-esteem and appearance satisfaction between pre and postsurgical phases in patients undergoing orthognathic surgery and to assess the quality of life and psychosocial changes of these patients six months after surgery. 

Methods: A longitudinal observational qualitative study was performed. The sample comprised 15 patients with dentofacial deformities who underwent orthognathic surgery. One questionnaire and two forms were answered during pre and postoperative phases. 

Results: The results showed that 13.3% of patients demonstrated self-esteem improvement, especially in relation to appearance satisfaction. Improvements were also noted in social, occupational and family relationships. With regard to the assessment of quality of life, according to the World Health Organization questionnaire, the lowest improvement averages corresponded to environmental control. 

Conclusion: Orthognathic surgery brings along many emotional changes that should be considered before and after surgery, since the patients? psychological state may be favorable and/or unfavorable during recovery, influencing their quality of life, self-esteem and appearance satisfaction. 

Evaluation of the vertical alterations of the upper second molars after the alignment and leveling phase using the MBT technique

Dental occlusion. Design of orthodontic appliances. Radiography. Corrective orthodontics.

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Objective: This study aimed at comparing the distocervical angulations of upper second molars crowns of groups with normal occlusion and with Angle Class I and II malocclusions. Additionally, it aimed to analyze the changes occurring after alignment and leveling performed with MBT technique. 

Methods: The sample of normal occlusions comprised 32 lateral teleradiographs, while the sample of malocclusions comprised 38 initial and post-leveling lateral teleradiographs. 

Results: The results did not show statistically significant differences between morphological characteristics of the normal occlusion group and the malocclusion group. On the other hand, after alignment and leveling, statistically significant reduction was observed in distocervical inclinations with extrusion of the distal portion of upper second molars.

Influence of treatment including second molars on final and postretention molar angulation

Panoramic X-ray. Tooth angulation. Tooth movement.

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Objective: Evaluate axial mesiodistal inclinations of the mandibular molars in orthodontically treated cases, analyzing whether inclusion of second mandibular molars in treatment mechanics has any influence on final and postretention molars angulations. 

Methods: The sample comprised 150 panoramic radiographs of 50 patients. Patients were treated with extraction of four first premolars and divided into 2 groups: Group 1 comprised 25 subjects without inclusion of mandibular second molars during orthodontic treatment, whereas Group 2 comprised 25 subjects with inclusion of mandibular second molars. Panoramic radiographs at three observation times were evaluated: pretreatment, posttreatment and postretention. The statistical analysis included one-way analysis of variance (ANOVA) for intragroup evaluation and independent t-tests for intergroup comparisons. 

Results: Intragroup analysis demonstrated significant uprighting of mandibular first and second molars during treatment in Group 2, which remained stable during the postretention stage. Intergroup comparison demonstrated that Group 2 presented first and second molars significantly more uprighted in relation to Group 1 in both post-treatment and postretention stages. 

Conclusions: It was concluded that inclusion of mandibular second molars in the orthodontic mechanics is relevant not only to correct the angulation of these teeth, but also to aid mandibular first molars uprighting.

Intra-articular injections with corticosteroids and sodium hyaluronate for treating temporomandibular joint disorders: A systematic review

Corticosteroids. Sodium hyaluronate. Temporomandibular joint. Temporomandibular joint dysfunction syndrome. Temporomandibular joint disorders.

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Introduction: In some cases, conservative treatment of internal derangements of the Temporomandibular Joint (TMJ) is considered little responsive. Thus, it is necessary to accomplish treatments that aim at reducing pain and improve patients? functions who present arthrogenic temporomandibular disorders. 

Objective: This study, by means of a systematic review of the literature, aimed to analyze the effectiveness of intra-articular injections with corticosteroids and sodium hyaluronate for treating internal derangements of the TMJ. 

Methods: Carry out a research in the following databases: MEDLINE, Cochrane, EMBASE, Pubmed, Lilacs, and BBO, considering publications issued between 1966 and October of 2010, focusing on randomized or quasi-randomized controlled clinical trials, single or double-blind. 

Results: After applying the inclusion criteria we collected 9 articles, 7 of which were randomized controlled double-blind clinical trials and 2 randomized controlled single-blind clinical trials. 

Conclusion: After analyzing the literature, it was found that intra-articular injection with corticosteroids and sodium hyaluronate seems to be an effective method for treating internal derangements of the TMJ. However, further randomized controlled clinical trials, with representative samples and longer follow-up time must be carried out in order to assess the real effectiveness of this technique.

Therapeutic exercises for the control of temporomandibular disorders

Temporomandibular joint dysfunction syndrome. Myofascial pain syndromes. Physical therapy modalities. Exercise.

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Introduction: Temporomandibular disorder (TMD) is a multifactorial disease. For this reason, it is difficult to obtain an accurate and correct diagnosis. In this context, conservative treatments, including therapeutic exercises classified as stretching, relaxation, coordination, strengthening and endurance, are oftentimes prescribed. 

Objective: Thus, the aim of the present article was to conduct a literature review concerning the types of exercises available and the efficacy for the treatment of muscular TMD. 

Methods: The review included researches carried out between 2000 and 2010, indexed on Web of Science, PubMed, LILACS and BBO. Moreover, the following keywords were used: Exercise, physical therapy, facial pain, myofascial pain syndrome, and temporomandibular joint dysfunction syndrome. Studies that did not consider the subject ?TMD and exercises?, used post-surgery exercises and did not use validated criteria for the diagnosis of TMD (RDC/TMD) were not included. 

Results: The results comprised seven articles which proved therapeutic exercises to be effective for the treatment of muscular TMD. However, these studies are seen as limited, since therapeutic exercises were not applied alone, but in association with other conservative procedures. In addition, they present some drawbacks such as: Small samples, lack of control group and no detailed exercise description which should have included intensity, repetition, frequency and duration. 

Conclusion: Although therapeutic exercises are considered effective in the management of muscular TMD, the development of randomized clinical trials is necessary, since many existing studies are still based on the clinical experience of professionals.

BBO Case Report

Compensatory orthodontic treatment of Angle Class II malocclusion with posterior open bite

Angle Class II. Anterior open bite. Orthodontic camouflage.

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The present case report addresses the treatment of an Angle Class II malocclusion in an adult female patient, long face pattern, with posterior open bite and dental arches extremely expanded, due to previous treatment. The patient and parents rejection to a treatment with orthognathic surgery led to orthodontic camouflage of the skeletal discrepancies. This clinical case was presented to the Brazilian Board of Orthodontics and Facial Orthopedics (BBO) as one of the requirements to become a BBO Diplomate.

Special Article

Finishing procedures in Orthodontics: dental dimensions and proportions (microesthetics)

Orthodontics. Dentistry. Dental esthetics. Smile.

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Objective: The objective of the present article is to describe procedures that can be performed to achieve excellence in orthodontic treatment finishing. The content is limited to microesthetics, which comprises the concept of ideal dental dimensions and proportions (white esthetics) and its correlation with the periodontium (pink esthetics). Standards of normality are described both in their real dimensions (dental height and width), and in those effectively perceived by the observer, the virtual dimensions. 

Methods: The best scientific evidence was sought in the literature to support the clinical procedures that must guide the professional to obtain maximum esthetic quality on their treatments. Therefore, it is necessary to investigate what the other specialties in Dentistry expect from Orthodontics and, specially, what they have to offer. Clinical cases will be used to illustrate the dental movement that might maximize treatment outcome and to confront the ideal standards with the current state of the art. 

Conclusion: Treatment quality is directly related to the amount of procedures implemented by the orthodontist, associated with concepts and resources from Periodontics and Dental Prosthesis. Microesthetics cannot be seen in isolation, but rather as the key to establish a pleasant smile (miniesthetics) in addition to a harmonious face (macroesthetics) and a human being with high self-esteem (hyper-esthetics). 

Dental Press Journal of Orthodontics - v. 18, no. 5 Download full issue pdf