THREE DIMENSIONAL EVALUATION OF CHANGES IN MAXILLARY SINUSES AND PHARYNGEAL AIRWAY IN CLASS III MAXILLARY DEFICIENCY CASES UNDERGOING ORTHOPEDIC FACEMASK TREATMENT

ORTHOPEDIC FACEMASK TREATMENT
I. ACKNOWLEDGEMENTS
First of all, I would like to express my endless love and deep gratitude to my
parents Emmanouil and Irini and to my sister Christina for their love and moral
support. I cannot imagine my life without them.
I would also like to express my gratitude to my thesis supervisor Professor Dr.
Nazan Küçükkeles, whose knowledge and experience led to the completion of this
research project. Her consistent advice and encouragement is highly appreciated.
My special thanks to Assist.Prof. Dr irin Nevzatolu for the valuable help she
offered during the treatment of my thesis patients and to Dr. Melih Motro and Dr.
Kadir Beycan for the help they provided with the operation of MIMICS software.
I would also like to thank all other faculty members, Professor Dr. Nejat Erverdi,
Professor Dr Sibel Biren, Professor Dr Ahu Acar, Professor Dr. Banu Çakrer,
Assoc.Prof. Dr. Toros Alcan, Assist.Prof. Dr Mustafa Ate and Dr. Nuray Ylamz
who gave me the opportunity to be a member of this department and shared their
knowledge with me.
Last but not least I would like to express my love to all my friends one by one and
thank them for the great moments we shared the last 4 years in the clinic. Maria,
Anas, Antony, Aved, Ayegül, Berza, Buket, Cihan, Elena, Evin, Ilia, Il, Kadir,
Marifei, Müge, Pnar, Taso, Yasemin, I will always remember you with so much joy!
BEYAN
Bu tezin kendi çalmam olduunu, planlanmasndan yazmna kadar hiçbir
aamasnda etik d davranmn olmadn, tezdeki bütün bilgileri akademik ve
etik kurallar içinde elde ettiimi, tez çalmasyla elde edilmeyen bütün bilgi ve
yorumlara kaynak gösterdiimi ve bu kaynaklar kaynaklar listesine aldm, tez
çalmas ve yazm srasnda patent ve telif haklarn ihlal edici bir davranmn
olmadn beyan ederim.
21 Temmuz 2012
AFFIRMANCE
I affirm that this thesis study belongs to me. There is no immoral attitude in all
stages from the planning stage of thesis to the writing stage. I gained all the
information in the terms of academic and ethical rules. I stated sources for the
information gained not with this thesis study. I showed the source in the list of
sources, and again there is no copyright infringement in study and writing stage.
21 July 2012
4. LITERATURE REVIEW 5
4.4.1 Etiology of midfacial deficiency 11
4.4.2 Etiology of maxillary transverse deficiency 13
4.4.2.1 Congenital 13
4.4.2.2 Developmental 14
4.4.2.3 Iatrogenic 15
4.4.2.4 Trauma 15
4.4.3.1 Syndromatic 16
4.4.3.2 Environmental 16
4.4.3.3 Congenital 16
4.5 Diagnosis of Class III malocclusion 17
4.5.1 Diagnosis of midfacial and malar deficiency 17
4.5.2 Diagnosis of transverse maxillary deficiency 23
4.5.3 Diagnosis of mandibular prognathism 25
4.5.4 Diagnosis of pseudo-class III malocclusion 27
4.6 Growth pattern in patients with Class III malocclusion 29
4.7 Correct timing for treatment of Class III malocclusion 31
4.8 Treatment approaches in Class III malocclusion 35
4.8.1 The Functional Regulator 36
4.8.2 Other intraoral appliances 39
4.8.3 Chin Cup 40
4.8.5 Protraction Facemask 44
4.8.5.2 Major animal tests using orthopedic facemask appliance 46
4.8.5.3 Assessment of dental and skeletal changes caused by facemask 49
4.8.5.4 Assessment of soft tissue and profile changes caused by facemask 53
4.8.5.5 Rapid palatal expansion before facemask use 54
4.8.5.6 Banded and bonded appliances along with facemask use 56
4.8.5.7 Facemask treatment timing 57
4.8.5.8 Stability of facemask treatment therapy and retention protocols 59
4.9 Anatomy and development of pharyngeal airway 61
4.9.1 Pharyngeal airway and facemask 63
4.10 Anatomy and development of maxillary sinuses 65
4.10.1 Maxillary sinuses and facemask 68
4.11 Cone Beam Computerized Tomography Imaging 69
4.12 Airway studies and CBCT 69
5. MATERIALS AND METHODS 71
5.1 Patient selection 71
5.2.1 Impressions 73
5.3 Treatment protocol 75
5.3.2 Delivery of facemask 75
5.4. Retention protocol 77
5.5 Data gathering 77
5.7 Assessment of the Pharyngeal airway 79
5.8 Assessment of the maxillary sinuses 80
5.9 Assessment of skeletal changes 81
5.10 Statistical Method 82
6.2 Results 110
7. DISCUSSION 121
7.2 Discussion of results 134
8. CONCLUSIONS 150
9. REFERENCES 151
10. BIOGRAPHY 176
3. gr: Gram
5. Materialize Interactive Medical Image Control Systems
6. h: Hour
7. d: Day
8. mm: Millimeter
10. fig: Figure
11. %: Per cent
13. et al.: And others
14. °: Degrees
31. FR III: The Functional Regulator
32. FOMA: Functional orthopedic magnetic appliance
33. vs.: Versus
36. MDCT: Multi Detector Computed Tomography
37. OSA: Obstructive sleep apnea
38. MRI: Magnetic Resonance Imaging
39. FMU: Facemask use
41. 2D: Two dimension
42. 3D: Three dimension
44. SD: Standard Deviation
52. T0 : Before treatment
53. T1: After treatment
66. U.P.A.D (Upper Pharyngeal Airway Difference)
67. L.P.A.D (Lower Pharyngeal Airway Difference)
68. T.P.A.D (Total Pharyngeal Airway Difference)
69. R.M.S.D (Right Maxillary Sinus Difference)
70. L.M.S.D (Left Maxillary Sinus Difference)
71. T.M.S.D (Total Maxillary Sinus Difference)
72. SPSS: (Superior Performance Software System
73. P: Probability
75. PT: Pterygomaxillary fissure
76. C3: Third vertebra
80. US: United States
IV. FIGURE AND TABLE LIST
Figure 4.1: Portrait and coin of the Habsburg dynasty
Figure 5.1: Frontal image before treatment
Figure 5.2: Profile image before treatment
Figure 5.3: Intraoral images before treatment
Figure 5.4: Extraoral images of Hyrax appliance
Figure 5.5: Intraoral images after RPE
Figure 5.6: Frontal image of patient wearing facemask
Figure 5.7: Profile image of patient wearing facemask
Figure 5.8: Superior image of facemask
Figure 5.9: Frontal image after treatment
Figure 5.10: Profile image after treatment
Figure 5.11: Intraoral images after treatment
Figure 5.12: Bionator III (retention appliance)
Figure 5.13: Thresholding
Figure 5.15: Measuring 10mm vertically over PNS
Figure 5.16: Cropping procedure
Figure 5.17: Identification of most anterior and inferior point of 3d vertebrae
Figure 5.18: Three dimensional reconstruction of measured airway
Figure 5.19: Split of total airway in upper and lower
Figure 5.20: Three dimensional reconstruction of upper and lower airway
Figure 5.21: Right sinus
Figure 5.23: Three dimensional reconstructions of right and left sinuses
Figure 5.24: Thresholding
Figure 5.27: Creation of posttreatment STL
Figure 5.28: Manual superimposition
Figure 5.30 Superimposing (frontal view)
Figure 5.31: Superimposing (top view)
Figure 5.32: 3-matic image
Figure 5.35: RP1
Figure 5.40: Pre and posttreatment A point identification
Figure 5.41: Pre and posttreatment PNS point identification
Table 5.1: Age and gender distribution of the study
Table 5.2: Age and gender distribution of the sample according to the applied
force
Table 6.3: Before treatment measurements
Table 6.4: After treatment measurements
Table 6.5: Distribution of the parameters of the study
Table 6.6: Assessment air volumes and force groups
Table 6.7: Assessment force groups and skeletal parameters
Table 6.8: Evaluation of volume differences according to force magnitude
Table 6.9: Evaluation of skeletal differences according to force magnitude
Table 6.10: Evaluation of the results of the treatment on air volumes
Table 6.11: Evaluation of the results of the treatment on skeletal structures
Table 6.12: Correlation of pharyngeal airway changes with skeletal changes
Table 6.13: Correlation of pharyngeal airway changes with skeletal changes in
two different force groups
Table 6.14: Correlation of pharyngeal airway changes with skeletal changes in
two different age groups
Table 6.15: Assessment of differences in airway volume changes between
different duration of treatment -force groups
1. SUMMARY
The title of the present thesis is: “Three dimensional evaluation of changes in
maxillary sinuses and pharyngeal airway in class III maxillary deficiency cases
undergoing orthopedic facemask treatment”.
The aim of this study was to assess short term alterations in the volume of
maxillary sinuses and pharyngeal airway space (PAS), associated with facemask use
in growing Class III maxillary deficient patients. .
Twenty two patients were selected for treatment. Mean age for the study group
was 10 years. All patients were diagnosed with normal or low vertical growth
pattern, with maxillary deficiency and normal mandible.
For each patient, hyrax expansion screw with acrylic cap splint was constructed
and rapid palatal expansion was performed for 7 days. At the 7th day, protraction
therapy with a Pettit type face mask started.
The patients were treated with maxillary protraction therapy for an average period
of 10 months. The appliance was removed when an overjet of 5mm and full Class II
molar and canine relationship were achieved. Then patients were treated with a
Class III bionator for retention, for a period of 3 months.
Volumetric measurements were performed in order to reconstruct three-
dimensional images and calculate the volume of the pharyngeal airway and the
maxillary sinuses.
The results showed a statistically significant increase in the volume of maxillary
sinuses after treatment. On the other hand the increase in the volume of pharyngeal
airway was not statistically significant. When we took into consideration the
available in the literature dada concerning the normal growth of maxillary sinuses
and pharyngeal airway, we reached the verdict that our treatment didn’t affect at all
the volume of maxillary sinuses and actually inhibited the normal expected increase
of the volume of pharynx.
Key words: Pharyngeal airway, maxillary sinus, Cone Beam Computed
Tomography, facemask treatment.
2. ÖZET
Bu tezin bal: “Ortopedik Yüz Maskesi Tedavisi gören Snf III maksiller
yetersizlik vakalarnda sinus boluklar ve farengeal havayolundaki deiikliklerin üç
boyutlu deerlendirilmesi”.
Bu çalmann amac, büyümesi devam eden maksiller yetersizlie bal snf III
malokluzyona sahip yüz maskesi ile tedavi görmü hastalarda tedavinin maksiller
sinüsler ve farengeal hava yolu boluuna etkilerini incelemektir.
Çalmada 22 hasta kullanlmtr. Çalmadaki hastalarn hepsinin ortalama ya
10`dur. Tüm hastalar normal ya da düük yüz yüksekliine, normal boyutta ve
konumda alt çeneye ve yetersiz maksiller büyümeye sahiptir. Hastalarn iskeletsel
ya servikal büyüme yöntemine göre tayin edilmitir. Tüm hastalar aktif büyüme
periyodunun farkl aamalarndadr.
Tüm hastalara önce hyrax ekspansiyon vidas içeren akrilik splint yerletirilmi ve
7 gün süresince hastalarn viday çevirmesi istenmitir. Yedinci günde Petit tipi yüz
maskesi tedavisine balanmtr.
Yüz maskesi tedavisi yaklak 10 ay sürmütür. Apereyler, yaklak 5 mm overjet
ve snf II kanin ve molar ilikisi elde edilince çkarlmtr. Retansiyon döneminde
hastalar yaklak 3 ay süresince snf III bianatörü kullanmlardr.
Hacimsel deiiklikler tedavi banda ve yüz maskesi tedavisi sonunda alnan
konik nl bilgisayarl tomografi görüntüleri ile ölçülmütür.
Çalmann sonucuna göre tedavi sonunda maksiller sinüslerin hacminde
istatistiksel olarak anlaml bir art bulunmutur. Ancak farengeal hava yolu
boluklarndaki hacimsel art istatistiksel olarak anlaml deildir. Maksiller
sinüslerin ve hava yolu boluklarnn normal büyüme ve geliimi hakkndaki
literatürleri göz önüne alrsak yüz maskesi tedavisinin maksiller sinüslerin hacmini
arttrmadn, hatta farengeal hava yolu boluunun büyümesine engel olduunu
söyleyebiliriz.
tomografi, yüz maskesi.
3. INTRODUCTION AND AIMS
Skeletal Class III malocclusion has long been recognized as difficult and
intractable to manage with orthodontic treatment alone. Prior to the 1970s, the
orthodontic literature portrayed the Class III problem as one of mandibular
prognathism. Recent studies, however, suggest that the majority of Class III
malocclusions have maxillary retrusion as all or at least part of the structural etiology
(60, 207, 120, 265, 67).
Class III treatment has often been consisted of producing dental compensations
for the skeletal disharmony by proclining maxillary incisors and retracting the
mandibular anterior segment. Class III elastics are often used in conjunction with
mandibular first premolar extraction. This approach can result in increased gingival
recession and tooth mobility in the anterior segment, along with compromised facial
esthetics.
So, because this malocclusion is not limited to dental discrepancy but often
related to underlying skeletal problems, the ideal treatment should be directed
towards an alternative treatment approaches carried out in the mixed dentition period
and include the use of protraction headgear, chincup, and Fränkel III appliance.
Among those the most popular appliance nowadays is the protraction headgear and
more specifically the orthopedic facemask appliance.
Numerous of studies are available today in literature proving that facemask use in
growing patients causes remarkable dental, skeletal and soft tissue changes.
Due to these changes in hard and soft tissues, it has been suggested that facemask
treatment in growing Class III patients may alter the volume of pharyngeal airway
and maxillary sinuses.
The effect of maxillary protraction, by the use of facemask appliance, on the
dimension of human pharyngeal airway is a very controversial issue. Few studies are
published and all of them are based on two dimensional evaluation of pharyngeal
airway by the use of conventional cephalograms.
Hiyama et al. (109) and Mucedero et al. (172) concluded that the favorable
skeletal maxillary and mandibular changes produced by maxillary protraction with or
without RME were not associated with statistically significant changes in the sagittal
oropharyngeal and nasopharyngeal airway dimensions.
On the other hand, Sayinsu et al. (212), Ji-Won Lee et al. (141) and Emine
Kaygsz et al. (129) concluded that the nasopharyngeal but not the oropharyngeal
airway dimensions can be improved in the short term with maxillary protraction in
skeletal Class III children. Oktay and Ulkulaya (181) claimed that both naso-and
oropharyngeal volumes increased as a result of facemask treatment.
As long as the volumetric change of maxillary sinuses as a result of facemask use
in Class III growing children is concerned, there is no available study in the
literature. There are only three surveys available examining the maxillary sinus
volume change after RPE in growing patients. Motro (168) proved statistically
significant increase in the volume of maxillary sinuses in growing patients treated
with RPE. On the other hand, Garnett et al. (81) and Smith et al. (224) found no
statistically significant change in the maxillary sinus volume in growing patients
treated with RPE.
The purpose of the current study was to evaluate, using CBCTs, the pharyngeal
airway and maxillary sinus volume changes in Class III deficient growing patients
undergoing facemask treatment and to contribute to the literature on an issue that has
not been evaluated before in three dimensions of space.
4. LITERATURE REVIEW
4.1. History of Class III malocclusion
One of the most perplexing malocclusions to diagnose and treat is Class III
malocclusion, particularly in the mixed and late deciduous dentitions. This occlusal
problem is defined easily, not only by dental specialists and generalists but also by
the lay public. The appearance of a negative horizontal overlap of the incisors often
stimulates a parent to seek orthodontic treatment for her or his child (161).
The facial characteristics of Class III malocclusion were obvious to mankind
many years ago. Even thought there was lack of knowledge for people to
scientifically justify and categorize the problem, the unique appearance of a big
protruded mandible was observed in all human societies through history.
The first description of the problem appears in the middle of fourteenth century
with the portraits of the members of the Habsburg dynasty (87, 99). Of the many
attributes identified with the Habsburg dynasty it is the hereditary over-grown jaw
that captured the most attention. It is clearly visible in many of the increasing natural
portraits (fig.4.1) of the family from the Renaissance and after and also is seen on
coinage of the period (fig 4.1), (The coin of Leopold the “Hogmouth” shown
demonstrates the deformity.) What we know is that the deformity developed and
increased with the age of the victim. Sometimes so serious as to inhibit talking or
eating, and often linked to a lack of mental sharpness, the problem never interfered
with hereditary succession. Well served by an efficient bureaucracy, the Habsburgs
long endured despite increasing inattention to duty and only disappeared in Spain
due to the king's failure to produce an heir.
Certainly the very high degree of intermarriage between the various branches of
the Habsburgs greatly contributed to the prevalence of the problem (217). There were
multiple marriages of uncles and nieces, first cousins (not to mention second, third or
more distant), nephews and aunts.
Early writers employed various terms in their classifications to describe the
anomaly which today is known as the Class III malocclusion. Bourdet in 1737 (31)
called attention to the deformity in children with protruded chins. Fox in 1803 (74)
presented the first classification of dental irregularities. He based it on the labial or
lingual locking of the upper anterior teeth to the lower.
Fig 4.1 Portrait and coin of the Habsburg dynasty (Hart, Gerald D., "The
Habsburg Jaw", C.M.A. Journal, Ottawa, April 3, 1971, pp. 602)
The terms ‘‘edge to edge’’ and underbite were used by Delabarre (56) in 1819.
Throughout the literature many other descriptive terms were used to denote the
deformity, such as mesial occlusion, infraversion, anteversion, prenormal, progenic,
macrognathism, mandibular overbite, projection of the lower jaw, etc.
Angle (9) first published his classification of malocclusion in 1899. He said of
Class III, “the relation of the jaws was abnormal, all the lower teeth occluding mesial
to normal the width of one bicuspid or even more in extreme cases”. He observed in
addition that the mandibular angles of Class III cases were more obtuse than in the
normal. Moreover he stated that in a few cases there was an overdevelopment in
‘‘certain localities of the body’’. In other cases, where the jaw seemed normal in
form, he suggested that the protrusion was caused by the temporomandibular
articulation being farther anterior than normal.
After the categorization of Angle in 1899 various combinations of jaw
discrepancies were described by different authors. Individual cases were felt to be
characterized by a retruded maxilla or a prognathic mandible and some by a
combination of the two. Lischer in 1912 (148) and Case in 1921 (37) held that the
malocclusion of the teeth was but a symptom of the poor relationship of the jaws.
More specifically, Lischer claimed that the milder forms of Class III resembled those
of “neutrocclusions complicated by linguoversion of the upper incisors”. Hellman in
1931 (104) showed a case in which the jaws were normal in relationship to each
other but the teeth were in Class III relationship.
A more accurate approach to the morphologic problem of the Class III was made
after 1920 by the introduction of craniometry. Sicher and Krasa in 1920 (218)
compared 7 crania exhibiting Class III malocclusion with 40 possessing normal
occlusion. They concluded that the variation occurred only in the size of the lower
jaw. Greve in 1921 (91) by examining the same material with Sicher and Krasa
found the Class III crania to be partly “progenic” and partly “opisthogenic”. Phaf in
1923 (193) examined 754 crania, 13 of which were class III agreed with Sicher and
Krasa but also suggested that the alveolar arch of the upper jaw was affected to some
degree in the Class III as the maxillary teeth showed slight recession.
In 1931 the advent of Cephalometric radiology allowed clinicians to discern
precisely and accurately the underlying skeletal pattern of the class III malocclusion.
Nevertheless from 1931 until the beginning of the 1960s the orthodontic literature
portrayed the Class III problem as one of a mandibular prognathism. The most
important roentgenographic studies of that era done by Hellman in1939 (104), Bjork
in 1947 (28), Adams in 1948 (6) and Staph in 1948 (228) suggested mandibular
prognathism as the one and only part of the structural etiology of Class III.
Recent studies, however, suggest that the majority of Class III malocclusions have
maxillary retrusion as all or at least part of the structural etiology. Ellis and
McNamara (67) analyzed a sample of 302 adult Class III individuals who were
selected on the basis of molar relationship and found that one third of the sample had
a combination of maxillary skeletal retrusion and mandibular skeletal protrusion.
Pure maxillary retrusion and pure mandibular protrusion were found in 19.5% and
19.2%, respectively.
Guyer and co-workers (95) found that 25% of their 144 sample had pure
maxillary skeletal retrusion, whereas less than 20% of the patients had pure
mandibular prognathism. A combination of maxillary skeletal retrusion and
mandibular skeletal protrusion was found in approximately 22% of the sample.
Jacobson et al. (119) found approximately 25% of Class III malocclusions have a
component of maxillary skeletal deficiency; other studies (130) showed that 42%-
63%…