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The purpose of this article is to review and discuss the advances in the management of children born with cleft lip and palate (CLP) as it has evolved over the past 100 years. This overview is based on articles published in the American Journal of Orthodontics, which frequently changed its name, over the past century. Additionally, other journals will be cited as craniofacial anomalies became recognized during the 20th century and the biologic basis became refined, with the new discipline of genetics replacing the term hereditary and its connotations of eugenics. The Human Genome Project, completed in 2003, has now provided an understanding of syndromic and nonsyndromic CLP that has led to advances in the diagnosis and treatment of CLP in the 21st century. These evolving concepts will be discussed in an overview of the types of procedures published from 1915 to 2015 and the major transition in the mid-20th century from multiple uncoordinated interventions from various specialists to a coordinated team approach in which the orthodontist has a specific role in the timing and sequencing of interdisciplinary treatment goals. Major technologic advancements in treatment modalities and the contemporary approach to the health-related quality of life of the patient and the caregiver have resulted in their participation in treatment options and decisions. The requirement of informed consent reflects the legal doctrine that now emphasizes the ethical imperative of greater respect for patient autonomy in the decision-making process. The orthodontist no longer makes decisions alone, but rather with the team and the patient or the caregiver., (Copyright © 2015 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.)

Objectives: 1) To determine the concordance among surgeons on subjective assessments of nasolabial esthetics in children with repaired cleft lip; and 2) to evaluate longitudinal changes in nasolabial esthetics in relation to cleft lip revision surgery., Setting and Sample Population: School of Dentistry at University of North Carolina, Chapel Hill. Children with repaired unilateral cleft lip: 32 had lip revision surgery and 27 did not have surgery., Materials and Methods: Retrospective observational study from a non-randomized clinical trial. Ratings of nasolabial esthetics performed by six surgeons using the Asher-McDade scale at baseline and 12-month follow-up., Results: Concordance among surgeons ranged from poor to acceptable. Nasolabial ratings at follow-up were better in the Revision group than in the Non-Revision group, although differences were small. The most prevalent change in the Revision Group was improvement in one or more units on the scale, while 'no change' was most prevalent in the Non-Revision group. Participants in the Revision group were more likely to receive a 'no' in relation to the need for lip or nose revision at the follow-up visit., Conclusion: There were mild esthetic improvements observed in relation to lip revision surgery, which should be interpreted with caution given the subjectivity of the rating method used., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives : To determine the impact of orofacial clefts on the oral health-related quality of life of affected children and whether the oral health-related quality of life of children with orofacial clefts differs among different age groups. To assess whether the responses of children with orofacial clefts differ from the caregivers' perceptions of their child's oral health-related quality of life and compare with data from a control group. Design : Cross-sectional study. Patients/Setting : A total of 75 subjects with cleft lip and/or cleft palate (mean age, 13.0 years) from the Nationwide Children's Hospital Craniofacial Anomalies Clinic, as well as their caregivers, and 75 control subjects (mean age, 13.9 years). Main Outcome Measure : Self-reported oral health-related quality of life measured with the Child Oral Health Impact Profile, a reliable and valid questionnaire designed for use with children and teenagers. Results : Children with orofacial clefts had statistically significant lower quality of life scores than control subjects had for overall oral health-related quality of life, Functional Well-being, and Social Emotional Well-being. There was a statistically significant difference in the interaction of age group and Social-Emotional Well-being between children with orofacial clefts and control children. No statistically significant differences were found between the responses of children with orofacial clefts and their caregivers' reports. Conclusions : Presence of an orofacial cleft significantly decreases overall oral health-related quality of life, Functional Well-being, and Social-Emotional Well-being in children and adolescents. The negative impact of orofacial clefts on Social-Emotional Well-being is greater in 15- to 18-year-olds than in younger age groups. Children with orofacial clefts and their caregivers had very similar evaluations of the child's oral health-related quality of life.

Subjects: During January to July 2008 a questionnaire was mailed to 1085 subjects who had completed comprehensive orthodontic fixed-appliance treatment from 6 months to 6 years following active tooth movement. This yielded 280 responses (25.8% response rate) after 2 mailings, 3 months apart. The respondents ranged in age from 8 to 72 years. Respondents were from various socioeconomic groups and urban or rural environments. Identifiers allowed respondents to be classified into subgroups., Key Exposure/study Factor: Predictors of compliance among patients/subjects who were provided with removable vacuum-formed retainers (VFRs) or Hawley retainers in the postretention phase of orthodontic treatment., Main Outcome Measure: The main outcome measure was self-reported compliance with different types of removable orthodontic retainers worn during the postretention phase of treatment., Main Results: A logistic regression model identified probabilities of retainer wear, including a likelihood ratio to test the model parameters using chi-square statistics to identify significant variables. The model found age, gender, amount of time since braces were removed, type of retainer, and interpretation of compliance in retainer wear to be statistically significant variables. Time on retainer compliance revealed better compliance with VFR than Hawley retainers during the first 2 years after braces were removed, but then compliance increased with Hawley retainers and overall compliance was greater with Hawley retainers., Conclusions: Compliance with wearing removable retainers was initially better with VFRs but over time was greater with Hawley retainers, and esthetics was not a determinant. Several variables determined compliance, including age, gender, and type of retainer., (Copyright © 2012. Published by Mosby, Inc. All rights reserved.)

Aim: There is limited data on how temporary anchorage devices (TADs) are currently used in orthodontics. The aim of this study was to survey two groups of orthodontic providers-graduate orthodontic residencies and private practitioners-about their use., Methods: A 15-question survey was prepared and administered to all 61 accredited orthodontic residencies and an equal number of private orthodontic practitioners (all in the United States). A second survey was also included and provided to the residency programs., Results: The response rate was 63.9% for private practitioners and 70.4% for orthodontic residency programs. The majority of the residency programs (82.9%) and practitioners (69.2%) reported placing TADs in their practices. TADs were placed in 6.0% of the patients treated by private practitioner and in 5.3% of patients treated in residency programs. A combination of topical and local anesthesia was the anesthetic of choice for 59.0% of private practitioners and 65.0% of orthodontic residency programs. A large majority of the private practitioners (79.0%) and orthodontic residency programs (61.9%) reported that the TADs were loaded immediately. The most frequently cited use for TADs was anterior en masse retraction. In total, 27.9% of the residency programs used miniplates, compared to 17.9% of the practitioners., Conclusion: Since 2005, a large number of US programs have incorporated TADs into their didactic/research curriculum and residency programs. Both mini-implants and miniplates may have a far-reaching impact on the clinical practice of orthodontics for decades to come. This survey detailed the trends and differences between practitioners and residencies in the TAD utilization experience and provided important information that is otherwise not available in the literature.

Introduction: The information that details dental changes accompanying presurgical and postsurgical orthodontic treatment during orthognathic surgery treatment is disappointing and results in less than ideal surgical change, but it is largely derived from university clinic samples with patients treated by residents (clinical novices). In this study, we examined similar treatments performed by experienced practitioners and compared them with the novices' results., Methods: A sample of 72 Class II subjects treated by practitioners with a mean of 26.7 years of experience was selected. Inclusion criteria were consecutively treated surgical-orthodontic patients with mandibular advancement, rigid fixation, and good-quality lateral cephalograms. Pretreatment skeletal and dental variables were compared with those from a sample treated by novices in a previous study. Presurgical and final analyses were performed with analysis of covariance (ANCOVA), with pretreatment values as the covariate. An efficacy analyses for treatment phase and study comparisons was the final component., Results: The novices treated patients with significantly more severe Class II skeletal problems. For both studies, there were significant positive changes in the position of the mandible. The ANCOVA analysis showed that the experienced practitioners managed the bodily position of the maxillary incisors more effectively. The efficacy analysis showed no statistically significant differences between novices and experienced practitioners. For both novices and experienced practitioners, according to the ANB changes, nonideal incisor decompensation led to less than ideal final mandibular positions., Conclusions: The dental and skeletal mean changes and efficacy analysis for both novices and experienced practitioners showed that presurgical orthodontic treatment often does not fully decompensate the incisors; this then limits the surgical outcome., (Copyright © 2011 American Association of Orthodontists. Published by Mosby, Inc. All rights reserved.)

Introduction: The importance that prospective patients place on practice characteristics when choosing an orthodontic practice has not been extensively reported. The objective of this research was to develop a valid and reliable questionnaire to address the relative importance of orthodontic office and doctor characteristics for prospective patients or parents of child patients during the initial orthodontic office consultation., Methods: An initial questionnaire, based on published literature, was field-tested on 16 subjects to assess its validity. Based on the field test, the questionnaire was modified and tested for reliability by using a test-retest method. The questionnaire covered the following areas: doctor, office, staff, and finances. The reliability study included 2 groups of subjects: 12 consecutive prospective adult patients and 41 consecutive parents of prospective child patients. The questionnaires consisted of 43 and 50 questions for the adult patients and the parents of patients, respectively. The subjects rated the importance of practice characteristics in their selection of an orthodontic practice using a 100-mm visual analog scale anchored at "not important at all" and "most important.", Results: Reliability was analyzed by using the intraclass correlation coefficient (ICC). Summary scores of all 53 subjects showed excellent reliability (ICC, 0.88; range, 0.61-1.0). Summary scores of all 50 questions showed acceptable reliability (ICC, 0.70; range, 0.45-0.88). Twenty-one questions had excellent reliability (ICC, >.75), and 29 questions had fair-to-good reliability (ICC, 0.41-0.75). No questions showed poor reliability (ICC, <0.4)., Conclusions: The pilot study data indicated that the overall reliability of the questionnaire is acceptable., (Copyright © 2011 American Association of Orthodontists. Published by Mosby, Inc. All rights reserved.)

Introduction: This systematic review evaluated root resorption as an outcome for patients who had orthodontic tooth movement. The results could provide the best available evidence for clinical decisions to minimize the risks and severity of root resorption., Methods: Electronic databases were searched, nonelectronic journals were hand searched, and experts in the field were consulted with no language restrictions. Study selection criteria included randomized clinical trials involving human subjects for orthodontic tooth movement, with fixed appliances, and root resorption recorded during or after treatment. Two authors independently reviewed and extracted data from the selected studies on a standardized form., Results: The searches retrieved 921 unique citations. Titles and abstracts identified 144 full articles from which 13 remained after the inclusion criteria were applied. Differences in the methodologic approaches and reporting results made quantitative statistical comparisons impossible. Evidence suggests that comprehensive orthodontic treatment causes increased incidence and severity of root resorption, and heavy forces might be particularly harmful. Orthodontically induced inflammatory root resorption is unaffected by archwire sequencing, bracket prescription, and self-ligation. Previous trauma and tooth morphology are unlikely causative factors. There is some evidence that a 2 to 3 month pause in treatment decreases total root resorption., Conclusions: The results were inconclusive in the clinical management of root resorption, but there is evidence to support the use of light forces, especially with incisor intrusion., (Copyright (c) 2010 American Association of Orthodontists. Published by Mosby, Inc. All rights reserved.)

Objectives: Employ differential scanning calorimetry (DSC) and temperature-modulated DSC (TMDSC) to investigate thermal transformations in three mouthguard materials and provide insight into their previously investigated energy absorption., Methods: Samples (13-21mg) were obtained from (a) conventional ethylene vinyl acetate (EVA), (b) Pro-form, another EVA polymer, and (c) PolyShok, an EVA polymer containing polyurethane. Conventional DSC (n=5) was first performed from -80 to 150 degrees C at a heating rate of 10 degrees C/min to determine the temperature range for structural transformations. Subsequently, TMDSC (n=5) was performed from -20 to 150 degrees C at a heating rate of 1 degrees C/min. Onset and peak temperatures were compared using ANOVA and the Tukey-Kramer HSD test. Other samples were coated with a gold-palladium film and examined with an SEM., Results: DSC and TMDSC curves were similar for both conventional EVA and Pro-form, showing two endothermic peaks suggestive of melting processes, with crystallization after the higher-temperature peak. Evidence for crystallization and the second endothermic peak were much less prominent for PolyShok, which had no peaks associated with the polyurethane constituent. The onset of the lower-temperature endothermic transformation is near body temperature. No glass transitions were observed in the materials. SEM examination revealed different surface morphology and possible cushioning effect for PolyShok, compared to Pro-form and EVA., Significance: The difference in thermal behavior for PolyShok is tentatively attributed to disruption of EVA crystal formation, which may contribute to its superior impact resistance. The lower-temperature endothermic peak suggests that impact testing of these materials should be performed at 37 degrees C.

Introduction: Continuous evaluation of residents and the advanced education curriculum is required to maintain the quality of a program and ensure appropriate accreditation status. The purpose of this project was to describe the process of introducing the objective structured clinical examination (OSCE) into an advanced orthodontic education program and to evaluate its impact on the curriculum., Methods: To determine the content of the examination, 60 orthodontic practitioners were consulted to identify the most important clinical skills that an entry-level practitioner must be able to perform proficiently. From 18 critical clinical skills, 13 were evaluated by the OSCE in the areas of diagnosis, clinical evaluation and synthesis, and orthodontic technique. The OSCE was given to 3 classes of residents each year for 3 years (n = 46)., Results: The classes were tracked longitudinally, and the students' levels were evaluated cross-sectionally. Curriculum changes were evaluated for impact in areas of deficiency. There were no significant correlations between student confidence and performance or faculty prediction of proficiency and performance beyond the first year. Great gains in performance were observed between the first and second years of the 3-year program. All skills did not reach proficiency levels, and peak performance did not always occur during the third year. Some curriculum changes were fruitful, and others were not sustained by improved performance., Conclusions: An OSCE can provide important information regarding students and the curriculum in a clinically meaningful way that might be otherwise unattainable.

Objective: To develop a cephalometric determination of anteroposterior skeletal occlusion on the basis of a clinically rational "gold standard" and objectively determined cut points., Materials and Methods: Pretreatment cephalograms from 10- to 18-year-old Caucasian patients with a normal vertical face dimension were digitized. Facial profile line drawings were judged by orthodontist raters as Class I, II, or III. Subjects who met all inclusion criteria were divided into Class I, Class II, and Class III on the basis of the matched skeletal (facial) and dental occlusion and comprised our gold standard for anteroposterior skeletal occlusions. Cephalometric variables included ANB angle, McNamara analysis, Harvold unit differential, anteroposterior dysplasia index (APDI), and Wits analysis. Half the sample was used to derive skeletal classification norms using receiver operator characteristic (ROC) curves, and half the sample was used to test for diagnostic ability and to compare the diagnoses based on traditional cephalometric norms with the new norms., Results: Results of the study showed that ANB and McNamara analysis performed well with traditional and ROC-derived norms, whereas Wits, Harvold unit differential, and APDI showed fewer errors in diagnosis with ROC norms compared with traditional norms., Conclusions: The use of a single set of diagnostic norms for each analysis to distinguish between the skeletal classifications for the 10- to 18-year-age group proved to be highly successful for each of the analyses and performed as well or better than when using traditional norms based on age and sex.

Introduction: The purpose of this study was to evaluate the perception of facial attractiveness in profile digital photographs that were incrementally altered to produce different combinations of mandibular anteroposterior positions and lower anterior facial heights. The specific aims were to determine whether there is concordance between providers and consumers in their perceptions of facial attractiveness, and to evaluate whether interactions of the anteroposterior and vertical dimensions and the magnitude of these interactions influence perception of facial attractiveness., Methods: Profile digital photographs and cephalograms of 3 men and 3 women were used. The position of the jaw was altered incrementally with Dolphin imaging equipment (Dolphin Imaging and Management, Chatsworth, Calif), and booklets were created. One hundred raters (50 laypersons, 25 oral surgeons, 25 orthodontists) scored the profiles on a visual analog scale. All images were duplicated to test intrarater reliability. Factorial ANOVA with repeated measures and the Tukey-Kramer post-hoc test for multiple comparisons were used to test for differences in facial attractiveness. The level of significance was set at .05 (P = .05) for all analyses., Results: Intrarater reliability was good (ICC = 0.71), and general concordance was found between providers and consumers in their perceptions of facial attractiveness. Interactions of the anteroposterior and vertical dimensions and the magnitude of change in each dimension influence the perception of facial attractiveness., Conclusions: The results suggest that preferences of facial attractiveness by laypersons, orthodontists, and oral surgeons in central Ohio are generally in agreement. This information might assist clinicians in treatment planning and making recommendations.

Introduction: This purpose of this study was to examine the effects of a structured telephone call after orthodontic appliance placement on self-reported pain and anxiety., Methods: One hundred-fifty orthodontic patients were randomly assigned to 1 of 3 groups and matched for age, sex, and ethnicity. The subjects completed baseline questionnaires to assess their levels of pain (on a 100-mm visual analog scale) and anxiety (Spielberger's State-Trait Anxiety Inventory) before orthodontic treatment. After the initial archwires were placed, all subjects completed the pain questionnaire and state-anxiety inventory at the same time daily for 1 week. One group also received a structured telephone call demonstrating care and reassurance; the second group received an attention-only telephone call, thanking them for participating in the study; the third group served as a control., Results: Although both telephone groups reported significantly less pain (P = .005) and state-anxiety (P = .033) than the control group, there was no difference between the 2 telephone groups (P > .12 for pain; P > .81 for state-anxiety)., Conclusions: A telephone call from a health-care provider reduced patients' self-reported pain and anxiety; the content of the telephone call was not important.

Introduction: The peer assessment rating (PAR) index is a valid and reliable tool for measuring malocclusion on plaster models, but it has not been shown to be valid and reliable when used to score computer-based digital models. The purpose of this study was to determine whether the PAR index is a valid and reliable measure on digital models., Methods: The study sample consisted of 48 pairs of plaster and digital pretreatment models. One examiner, calibrated in the PAR index, scored the digital and plaster models. The overall PAR scores were examined for reliability and validity by using analysis of variance and the intraclass correlation coefficient (ICC). Reliability of the components of the PAR score was compared with values originally presented by Richmond et al (1992)., Results: No significant differences were found between overall PAR scores of plaster and digital models (P = .82), and scores were highly correlated (ICC = 0.95; lower confidence boundary (LCB) = 0.92; upper confidence boundary (UCB) = 0.97). Intraexaminer reliability was excellent for both plaster models (ICC = 0.98; LCB = 0.97; UCB = 0.99) and digital models (ICC = 0.96; LCB = 0.94; UCB = 0.98). Reliability of all components of the PAR score generated on digital models except for buccal occlusion was similar to those of Richmond et al., Conclusion: PAR scores derived from digital models are valid and reliable measures of occlusion.

The purpose of this study was to investigate the glass transition temperatures (T(g)) of representative elastomeric chain products (plastic modules) in the as-received condition and after orthodontic use to determine differences between brands and pigments. Values of T(g) were determined by differential scanning calorimetry. Products were obtained from 3 manufacturers: Rocky Mountain Orthodontics (RMO, Denver, Colo), Ormco (Glendora, Calif), and G&H (Greenwood, Ind). Three colors (gray, red, and purple) were selected for each brand-pigment combination to evaluate the as-received products, and test specimens for each brand-pigment combination from the same batches were placed in patients' mouths for 4 weeks to evaluate the products after clinical use (sample size of 7 specimens for both groups of experiments). Results were analyzed statistically by multiple nonparametric Mann-Whitney tests. A post hoc step-down Bonferroni analysis followed, to examine differences in T(g) due to pigmentation within brands and differences due to brands within each pigmentation category. For the as-received products, the RMO modules had mean T(g) ranging from -24 degrees C to -21 degrees C, whereas the Ormco and G&H modules had significantly lower mean T(g), ranging from -46 degrees C to -39 degrees C, indicating substantial compositional or polymer structural differences compared with the RMO modules. After clinical use, the RMO products had mean T(g) ranging from -31 degrees C to -25 degrees C, whereas the Ormco and G&H products had mean T(g) ranging from -46 degrees C to -30 degrees C. The in vivo specimens also exhibited a second, higher-temperature glass transition of unknown origin. Results suggest that the Ormco and G&H products should have greater flexibility than the RMO products and that there should be significant differences in clinical force-degradation behavior for the Ormco and G&H products compared with the RMO products.

For reasons of convenience and economy, orthodontists who routinely use and maintain pre- and posttreatment plaster casts are beginning to use computer-based digital models. The purpose of this study was to determine the accuracy (validity), reproducibility (reliability), efficacy, and effectiveness of measurements made on computer-based models. A plastic model occlusion ie, dentoform, served as a gold standard to evaluate the systematic errors associated with producing either plaster or computer-based models. Accuracy, reproducibility, efficacy, and effectiveness were tested by comparing the measurements of the computer-based models with the measurements of the plaster models--(1) accuracy: one examiner measuring 10 models made from a dentoform, twice; (2) reproducibility and efficacy: two examiners measuring 50 models made from patients, twice; and (3) effectiveness: 10 examiners measuring 10 models made from patients, twice. Reproducibility (reliability) was tested by using the intraclass correlation coefficient. Repeated measures of analysis of variance for multiple repeated measurements and Student's t-test were used to test for validity. Only measurements of maxillary and mandibular space available made on computer-based models differed from the measurements made on the dentoform gold standard. There was significantly greater variance for measurements made from computer-based models. Reproducibility was high for measurements made on both computer-based and plaster models. In conclusion, measurements made from computer-based models appear to be generally as accurate and reliable as measurements made from plaster models. Efficacy and effectiveness were similar to those of plaster models. Therefore, computer-based models appear to be a clinically acceptable alternative to conventional plaster models.

Longitudinal craniofacial databases, including the Fels Longitudinal Study, the Michigan Growth Study, and the Nijmegen (The Netherlands) Growth Study, were compared for a set of 12 craniofacial measurements on lateral skull cephalograms. The age ranges of the subjects were 7-14 years for females and 9-14 years for males. When we compared the normally distributed databases using multiple comparisons, a small sample test statistic t for differences between means of the databases showed few statistical differences. The databases were therefore pooled, and sex-specific Class I (ANB < 4 degrees), and Class II (ANB > or = 4 degrees) subsamples were analyzed with the same t test. The sizes of these subsamples ranged from 39 to 122 at the different ages. The findings showed that the Class II samples had greater SNA and SN-GoMe angles. Compared with the Class I group, shorter mandibles were found in the younger age groups of the Class II samples. No differences were found in mandibular length (Ar-Gn) and mandibular body length (Go-Gn) in the older Class II groups compared with the Class I groups. These findings indicate that the greater mandibular lengthening in the Class II groups might have contributed to successful Class II treatment in studies in which a Class I group was the control. Because of individual biological variability, the average Class I or Class II growth pattern might not be a realistic assumption or have clinical relevance for individual patients.

Occlusal indexes objectively quantify malocclusions. The index of complexity, outcome and treatment need (ICON) is a new index developed to measure several aspects of occlusion and treatment outcome. The purpose of this study was to test the validity of the ICON in measuring orthodontic complexity, outcome, and degree of improvement. Fifteen orthodontists evaluated 100 pairs of pretreatment and posttreatment study models for complexity, outcome, and degree of improvement. A calibrated examiner used ICON to score the casts. One month later, a random subset of 40 study casts was rescored by raters and the examiner for reliability testing. A simple kappa statistic was used to assess agreement between the scores from the expert panel and from the ICON examiner. Interrater agreement was moderate for complexity (kappa =.50), slight for outcome (kappa =.18), and poor for degree of improvement (kappa =.04). Reliability of the calibrated examiner was kappa =.90 for pretreatment and kappa =.83 for posttreatment casts. Agreement between the raters and the ICON scores was moderate for complexity (kappa =.52) and outcome (kappa =.50) and fair for degree of improvement (kappa =.27). ICON is valid for assessing cases for complexity and outcome. However, lack of agreement among the raters for degree of improvement and between the ICON-based evaluations and the orthodontists' evaluation of degree of improvement suggests that this component should be reexamined.

The difficulty of achieving an ideal or normal occlusion might lie in the pretreatment occlusion, patient-associated factors, and the treatment. The purpose of this study was to identify factors that were related to the treating orthodontist's posttreatment categorization of a case as difficult or easy. Ten orthodontists each identified 10 easy cases and 10 difficult cases that they had treated. The initial malocclusion was measured with the peer assessment rating (PAR) index and the index of orthodontic treatment need (IOTN). Patient and treatment information was obtained from the treatment records. Statistical analysis with parametric or nonparametric testing was performed. Difficult cases had greater severity and need before treatment and greater residual malocclusion and need after treatment. Difficult cases had more chart entries for problems with hygiene and compliance. They were more likely to have had extractions and changes in treatment plan. Difficult cases also required more appointments and a longer treatment duration. Three logistic regression models were developed based on malocclusion severity, patient characteristics, and treatment characteristics. The models support a correlation between greater pretreatment malocclusion severity, 1-phase treatment, and the designation as a difficult case. This study supports a model in which malocclusion severity and factors associated with the patient and the treatment contribute to an orthodontist's categorization of a case as easy or difficult.

Orthodontic studies over several decades have found generally inconsistent opinions among dentists when evaluating orthodontic treatment need. There has also been recent concern that dental school education does not sufficiently prepare dentists to diagnose malocclusion and make appropriate referrals of potential orthodontic patients. The purpose of this study was to investigate the efficacy of using the index of orthodontic treatment need (IOTN) as a tool to improve dental students' ability to assess orthodontic treatment need. Fourth-year dental students were randomly divided into control, sham-control, and experimental groups stratified for mean grade point average. On 2 occasions, the subjects evaluated 30 orthodontic study models with a gold standard previously established by an expert panel of 15 orthodontists for orthodontic treatment need. The experimental group reevaluated the models after IOTN instruction. Kappa statistics, sensitivity, and specificity were calculated for each subject. Analysis of covariance (ANCOVA) showed that the experimental group had significantly higher agreement with the expert panel after IOTN training than did either control group. IOTN is a promising teaching aid for improving educational outcomes for orthodontic referral.

The need for orthodontic treatment has an objective component based on occlusal traits and a subjective component based on the esthetic impact of the occlusion. An occlusal index that measures the objective deviation from normal or ideal occlusion might be sufficient to mirror the subjective opinion of orthodontists about treatment need. The objective of this study was to determine whether the American (US) and United Kingdom (UK) weightings of the peer assessment rating (PAR) index are valid instruments with which to determine treatment need. Fifteen orthodontists rated the need for orthodontic treatment of 170 casts. Their collective decision was compared with the PAR value for the cast determined by a calibrated examiner. A range of suggested treatment cutoff points from the literature was used to generate receiver operating characteristic (ROC) curves and optimized cutoff points. The cutoff points were 17 for both the US PAR and the UK PAR, and sensitivity, specificity, and kappa were 92%, 86%, and 0.77 for the US PAR and 92%, 89%, and 0.80 for the UK PAR. The area under the ROC curve was 97% for the US PAR and the UK PAR. Both the US PAR and the UK PAR scores were excellent predictors of orthodontic treatment need as determined by a panel of orthodontists. An occlusal index used to measure deviation from normal or ideal occlusion might perform as well as indexes of treatment need in predicting orthodontists' evaluations of treatment need.

Occlusal indices are used to determine eligibility for orthodontic treatment in several publicly funded programs. The Index of Complexity, Outcome, and Need (ICON), based on the perception of 97 orthodontists from 9 countries, has been proposed as a multipurpose occlusal index. The aim of this study was to investigate the validity of the ICON as an index of orthodontic treatment need compared with the perception of need as determined by a panel of US orthodontists. One hundred seventy study casts, representing a full spectrum of malocclusion types and severity, were scored for orthodontic treatment need by an examiner calibrated in the ICON. The results were compared with the decisions of an expert panel of 15 orthodontic specialists from the central Ohio area. The simple kappa statistic (0.81) indicated very high agreement of the index with the decisions of the expert panel. The sensitivity (94%), specificity (85%), positive predictive value (92%), negative predictive value (90%), and overall accuracy of the ICON (91%) also confirmed good agreement with the orthodontic specialists. The panel found that 64% of the casts required orthodontic treatment; the ICON scores indicated that 65% of the cases needed treatment. There was agreement between the expert panel and the index in 155 of the 170 cases. These results support the use of the ICON as a validated index of orthodontic treatment need.

Several occlusal indexes are currently used to ascertain eligibility for orthodontic treatment. A comparison of 3 indexes of orthodontic treatment need was made with the consensus opinion of a panel of 15 experienced orthodontists. Sets of study casts (170) representing the full spectrum of malocclusions were selected. An examiner, calibrated in the Dental Aesthetic Index, the Handicapping Labiolingual Deviation with the California Modification, and the Index of Orthodontic Treatment Need, scored the casts. The panel of orthodontists individually rated the same casts for their degree of orthodontic treatment need. The mean rating of the panel on the need for treatment was used as the gold standard for evaluating the validity of the indexes. Intrarater and interrater reliability was high (kappa > 0.8). Overall accuracy of the indexes, as reflected in area under receiver-operating characteristic curves, was also high: Dental Aesthetic Index, 95%; Handicapping Labiolingual Deviation with the California Modification, 94%; and Index of Orthodontic Treatment Need, 98%. Cutoff points for the indexes that resulted in the closest agreement with the gold standard differed from the published cutoff points for the indexes. The indexes appear to be valid measures of treatment need as perceived by orthodontists. The published cutoff points for the indexes were more conservative in assigning patients for treatment than a panel of orthodontists. However, adjusting the cutoff points moved all 3 indexes into close agreement with the experts.

Objectives: The aims of this study were to develop a reliable self-report measure of consumer satisfaction with orthodontic treatment, and to preliminarily assess its validity., Method: Transcripts of qualitative interviews with patients, their parents, and practicing orthodontists together with items from existing dental satisfaction questionnaires were used to develop a pool of 41 items assessing satisfaction with various aspects of orthodontic care. These items were paired with five-point Likert scales (1 = strongly disagree, 5 = strongly agree) and were administered to 299 parents of children who had completed orthodontic treatment at two university-based clinics., Results: Factor analyses and reliability analyses identified three main subscales with high reliabilities: 13 items assessing satisfaction with treatment process (Cronbach's alpha = .92), seven items assessing satisfaction with psychosocial effects of treatment (Cronbach's alpha = .87), and five items assessing satisfaction with overall treatment outcome (Cronbach's alpha = .79). Relationships among these three subscales and pre- and posttreatment variables were examined in a subset of 86 parents/patients. Forward stepwise regression with backward overlook revealed no significant relationships between any satisfaction subscale and demographic variables. Posttreatment overjet was inversely related to parental satisfaction with orthodontic treatment process (R2 = .13; P < .001), and parent satisfaction with treatment outcome (R2 = .28; P < .0001). Improvement in esthetics as measured by improvement in IOTN Aesthetic Component scores was positively related to satisfaction with psychosocial outcomes (R2 = .28; P < .0001)., Conclusions: The present instrument is reliable and can be used to assess three dimensions of parental satisfaction with their child's orthodontic treatment. Relationships between visible orthodontic outcome variables and parent satisfaction provide preliminary validity support for the instrument.

The purpose of this retrospective longitudinal study was to compare 7 cephalometric measurements of the cranial base in subjects with Class I and Class II skeletal patterns at ages 1 month, 2 years, and 14 years. A sample of 22 Class I and 21 Class II subjects was selected; the inclusion criteria were overjet, ANB, and Harvold unit difference. Analyses of head circumference, crown-rump length, and weight revealed no significant (P >.15) differences between the Class I and Class II infant subjects at the initial age (1 month). One angular and 6 linear measurements were first compared with a multivariate analysis of variance, which revealed significant effects for age (P <.0001) and the age by skeletal pattern interaction (P =.0266) but not for skeletal pattern (P =.3705). Analyses of variance showed significant (P <.0001) age effects for each of the cephalometric variables but no significant skeletal pattern effects (P >.10). The anterior cranial base measurement of nasion to sphenoethmoidal suture was the only variable found to have a significant age by skeletal pattern interaction (P <.006), which revealed a difference in the timing of its growth spurt that occurred between 1 month and 2 years in the Class I subjects and between 2 years and 14 years in the Class II subjects. There were no significant differences between the skeletal classes at any of the 3 ages evaluated. Conclusions from this study indicate that cranial base growth patterns are similar for Class I and Class II subjects and that the premise of a more obtuse "saddle angle" or cranial base angle in Class II skeletal patterns was not supported.

Cephalometric analysis of skeletodental features is accepted as an integral part of orthodontic diagnosis and treatment planning. This assumes that diagnostic cephalometric variables affect prognosis and thus help reduce malocclusion severity, which is the aim of orthodontic treatment. The aim of this study was to assess the predictive value of 41 commonly used cephalometric parameters with regard to pretreatment severity and treatment outcomes. Pretreatment severity was assessed by using the Peer Assessment Rating (PAR) occlusal index, an instrument that has been shown to be valid and reliable. Treatment outcomes consisted of (1) posttreatment malocclusion severity (post-PAR), (2) relative improvement (percent PAR reduction), and (3) treatment duration. Complete records, including cephalograms, of 223 treated Class II cases were analyzed by means of separate multiple linear regression models. Each of the outcome variables and the pretreatment severity served as the respective dependent variables, and the cephalometric parameters served as the independent or predictor variables. The cephalometric parameters explained 39.2% of the pretreatment severity variance, 17. 9% of posttreatment severity variance, 15.7% of relative treatment improvement variance, and 20.0% of treatment duration variance.

This article enables pediatricians to identify and understand the implications of common facial growth problems in children and adolescents. Problems with facial growth can result in aesthetic and functional concerns. Using a simple method of clinical evaluation, pediatricians can identify facial growth problems in the anteroposterior, vertical, and transverse dimensions. These problems can then be referred for evaluation and treatment by various means. Because facial growth is the result of the interaction of genetic and environmental factors (some of which are functional), growth modification may be a possibility. Some problems may be camouflaged or treated by combined surgical and orthodontic means. Continued growth in early adulthood may enhance or detract from treatment results obtained in childhood or adolescence. These dynamic properties of the face make management of facial growth challenging but generally rewarding and successful because of substantial aesthetic and functional improvements.

The purpose of this paper is to discuss the management of the cleft maxilla with emphasis on the controversies concerning the decisions which a cleft palate team makes with limited evidence but strong beliefs in the anticipated outcomes. The orthodontist and the surgeon need to collaborate in determining the timing and sequencing of alveolar bone grafting. Currently the emphasis on secondary bone grafting has superseded primary bone grafting in its effectiveness and efficiency. Contemporary management of infants born with clefts of the lip and palate is to delay bone grafting until the early mixed dentition stage of dental development with the optimal timing being related to the development of the unerupted permanent canine. In the management of patients with cleft palate, the surgeon and the orthodontist need to evaluate the mixed dentition stage of dental development to determine the optimum timing of treatment to coincide with the most favourable eruption of the maxillary canine or the lateral incisor when this tooth is on the distal side of the cleft. The issues which have led to controversy relate to (i) the age at which alveolar bone grafting should be performed, (ii) the type of bone graft and the site from which the donor bone will be harvested and (iii) the timing of the maxillary expansion and whether this should be performed before or after the alveolar bone graft is placed. A review of contemporary management of the palatal and alveolar cleft is discussed and illustrated in unilateral and bilateral clefts of the maxilla.

During the past decade, emphasis in orthodontics has been directed toward the development of outcome measures from both the patient and clinician perspectives. New methodological standards of rigor have been introduced into research design to eliminate bias and test well-defined questions. Sample size calculations and established exclusion and inclusion criteria define sample populations and the ability to statistically accept or reject hypothesis-driven clinical studies. Although advances in our understanding of evidence-based medicine and dentistry from the provider perspective have been productive, the emerging value placed on patient perspective has not been as forthcoming. The emphasis placed on patient-oriented clinical research has resulted in new constructs of surveys and questionnaires in which the items are derived and tested from the patient's point of view. Because orthodontics is a condition without the natural history of a disease process for which no intervention has predictable consequences, new strategies have been developed to estimate need and demand for orthodontic treatment. Studies to measure seekers and nonseekers of orthodontic treatment are reported, as well as sex and cross-cultural issues in the use of established process and outcome measures. The design of clinical studies is discussed in the context of future directions for clinical research, and the usefulness of the information generated will directly relate to providing patients with the necessary information to make decisions and hence knowledgeably give informed consent for treatment interventions.

Objectives: The aim of this preliminary study was to assess the nature of associations between selected dentofacial morphological variables and respiratory mode as measured by percent nasality (%N) as part of an ongoing longitudinal study., Design: Cross-sectional cohort study., Setting and Sample Population: The Pediatric Clinical Study Center, Children's Hospital, Columbus, OH. Ninety-eight normal children were tested., Experimental Variable: Normal variation in %N., Outcome Measure: Selected dentofacial morphological variables including total and lower anterior face heights, face width, and palatal arch width and %N were estimated., Results: Small associations between morphologic features and respiratory mode were found, but none were statistically significant., Conclusion: No evidence exists for the classic association between 'mouth breathing' and the stereotype of the 'adenoid facies'.

The development of process and outcome measures in orthodontics lends itself to retrospective clinical studies. Once valid and reliable measures have been tested, prospective studies may utilize these measures to assess the quality of orthodontic treatment outcome and the duration and process of treatment. The findings from two retrospective studies comparing the quality of outcome using the peer assessment rating (PAR) occlusal index and duration of treatment are reported. Class I and Class II treatment comparisons indicate the duration of treatment time is increased on average 5 months in Class II, division 1 patients. In the second study, the effect of extraction/non-extraction treatment in a sample that included all types of malocclusion indicates that, on average, treatment time is increased by approximately 5 months when extractions are included as part of the orthodontic treatment plan.

The orthodontic relevance of nasorespiratory obstruction and its effect on facial growth continues to be debated after almost a century of controversy. The continuing interest in nasal obstruction is fueled by strong convictions, weak evidence, and the prevailing uncertainty of cause and effect relationships that exist. The essence of any debate is to provide opposing evidence from which a majority vote is obtained. Political issues may be appropriately resolved by such means as a majority vote. Scientific issues, however, can only be resolved by data and appropriately structured hypotheses put to the test. One of the problems in debating nasorespiratory obstruction and facial growth is the inability to provide unequivocal answers to such issues as: How much nasal obstruction is clinically significant? At what age is the onset critical and for how long does it have to exist before an effect on facial growth can be expected? To provide unequivocal answers, clinical studies need to be designed to identify and quantify the degree of nasorespiratory obstruction and compare individuals for any clinically relevant differences. The purpose of this article is to review the available evidence. If both data and untested popular beliefs are subjected to the same rigorous criteria, indications for the orthodontic management of patients with nasorespiratory obstruction may gain a more rational approach to treatment recommendations.

The purpose of this study was to evaluate an intraoral, nontooth-borne, submucosal distraction appliance in the pig mandible from a clinical, radiographic, and histologic perspective. Intraoral distraction appliances were fabricated, tested for strength, and then adapted and rigidly fixated to the mandibles of three growing miniature Yucatan pigs. A bicortical osteotomy was performed on the right side of the mandible, and a buccal and lingual corticotomy on the left. Two amalgam markers were placed on each side of the osteotomy/corticotomy sites as references. Measurements were taken to evaluate the length and vector of the distraction site, and radiographs were obtained perioperatively. After a latency period of 5 days, distraction was commenced and continued for 13 days at a rate of 1 mm/day. Clinical evidence of distraction was apparent in all cases, with resulting Class III skeletal deformities. Distraction progressed further for the corticotomy sides than the osteotomy sides because of distraction device failure. Radiographic examination revealed increased bone density at the periphery of the distracted callus, with less density apparent centrally. Histologic examination showed fibrous connective tissue in the center of the callus, with cartilage and osteoid formation at the periphery. Bone formation was parallel to the vectors of distraction in all cases. This study confirms that the use of a modified intraoral appliance for distraction osteogenesis is feasible. Use of this device overcomes many of the problems associated with extraoral devices and may have clinical applications.

The purpose of this study was to compare the reliability and validity of three occlusal indexes of orthodontic treatment need in predicting the opinion of treatment need of a panel of 18 orthodontists. A set of 160 study casts representing all types of malocclusion was used. The casts were scored with the following occlusal indexes: the Index of Orthodontic Treatment Need (IOTN), the Handicapping Labio-Lingual Deviations index (HLD), and the Handicapping Malocclusion Assessment Record (HMAR modified). The diagnostic accuracy or validity of each index was calculated using the mean opinion of the orthodontic raters as a "gold standard". Receiver Operating Characteristic curves were plotted for each index. The overall diagnostic accuracy, as determined by percent area under the curve, was similar for each index: IOTN 98.6%; HLD 96.1%; HMAR 96.6%. The score optimizing the sensitivity and specificity relationship for each index was as follows: IOTN (dental health component) 4; HLD 13; HMAR 12. These results indicate that the three occlusal indexes provided valuable information for determining orthodontic treatment need.

The relationship between respiration and craniofacial morphology has been debated for many years. Despite numerous studies, the term 'mouth breathing' remains ill-defined. Still, medical and surgical treatments are performed in order to modify respiration and 'improve' facial growth. This clinical belief continues, in the absence of conclusive evidence, that a causal relationship exists between oral respiration and facial growth, or that such treatment modalities and their associated risks actually modify respiratory mode. Moreover, diagnostic indicators have been postulated for the identification of patients for whom such therapy would be beneficial. The purpose of this study was to investigate the strength of association between mode of respiration and craniofacial morphology. In addition, the precision level was calculated for two popular cephalometric tests for possible nasal impairment. The results suggest that: (1) cephalometric analyses are poor indicators of nasal impairment and should not be used in clinical decision making, and (2) facial morphology and respiratory mode are unrelated.

The aim of this retrospective study was to evaluate the effectiveness of orthodontic treatment in terms of two outcome variables, namely, the percentage change in a valid and reliable occlusal index, the Peer Assessment Rating (PAR) score, and the duration of treatment. Data were collected from the records of 250 patients with Class II, Division 1 malocclusions who were treated in the Orthodontic Department of the University of Pittsburgh between 1977 and 1989. The relationships between the outcome and the treatment variables were analyzed with multiple regression techniques. Those variables significantly associated with the duration of treatment (p < 0.01) were (1) the pretreatment PAR score, (2) the number of treatment stages, (3) the percentage of appointments attended, (4) the number of appliance repairs, and (5) whether the patient was treated with or without extractions. The only variable that influenced the percentage change in PAR was the pretreatment PAR score (p < 0.01).

The Peer Assessment Rating (PAR) index is a British occlusal index that measures the severity of dental malocclusion and has been used in several investigations that have evaluated the effectiveness of orthodontic treatment provision in Europe. As part of its development, the PAR index was validated for malocclusion severity, by using the opinions of a panel of 74 dentists and orthodontists. The present investigation was carried out to validate the PAR index, by using the opinion of an American panel of orthodontists. Eleven orthodontists examined a sample of 200 sets of study casts and rated them for malocclusion severity and perceived treatment difficulty. Multiple regression techniques were used to evaluate the predictive power of the components of malocclusion on the panel's scores. Weightings were calculated from the partial regression coefficients and, when these weightings were applied to the PAR index, the association between the panel's opinion and the PAR index scores was increased.

Measurements of patients' perceptions of the benefits, costs, and risks of orthognathic treatment are needed to assess the utility of alternative treatments, and to assess and improve patient education to make informed decisions. A two-part study was conducted to develop and evaluate measures assessing patients' perceptions of the benefits and risks of orthognathic surgery in comparison to an orthodontics-only approach or no treatment. The first part of this study included 49 patients who had completed orthodontics and orthognathic surgery and 34 patients considering orthognathic surgery. All patients were asked to complete an open-ended telephone questionnaire about their perceptions of the benefits and risks of orthognathic surgery and of alternative options. Patients' answers were sorted into categories, and the second part of this study included a closed-form written questionnaire to assess the perceived likelihood of possible outcomes in each category. Reliability of the questionnaire was assessed using Cronbach's alpha coefficient of internal consistency reliability. Cronbach's alpha ranged from 0.74 to 0.91 when the instrument was used to assess either overall benefits or risks of orthognathic surgery, orthodontics only, or no treatment, indicating acceptable reliability for each of these uses. Subscales concerning more narrowly defined aspects of benefits and risks were less reliable than the overall scales.

The successful outcome of orthognathic surgery is related to patient satisfaction and motivation. The aim of this retrospective study was to analyze the association between 1) severity of dentofacial deformity derived from cephalometric measures and 2) patient motivation for treatment. The initial cephalograms of 142 patients aged 16 years or older from the Dentofacial Program of the University of Michigan were traced and digitized. Inclusion criteria were established by assigning ANB 4 degrees to 15 degrees to define severe skeletal Class II (n = 65) and ANB - 15 degrees to -4 degrees to define severe skeletal Class III (n = 20). Motivation for orthodontics and surgery was derived from clinician administered forms scaled 1-10 with Low (1-5) and High (8-10). The cephalometric measure ANB was significant (p = 0.02) for high/low motivation for orthodontic treatment using Student's t test. No other cephalometric measures were significant for high/low motivation for orthodontics or surgery using Student's t test. Class II patients were significantly (p = 0.014) more motivated than Class III patients for orthodontic treatment. No significant difference was found for motivation for surgery between skeletal Class II and skeletal Class III patients. Patients with severe sagittal Class II deformities had higher motivation for orthodontics than surgery. The cephalometric measure, ANB, defining severe skeletal Class II and Class III patients did predict motivation level for orthodontics. None of the other 18 cephalometric measures were predictive of patient motivation for either orthodontics or surgery.

The purpose of this preliminary study was to evaluate tooth formation in children with idiopathic short stature, before and during treatment with recombinant growth hormone (rhGH). Twenty-nine short-statured children ages 6 to 13 years were assigned into two treatment groups, an "experimental" group (n = 18), which received rhGH, and a "control" group (n = 11), which was observed for 1 year before commencing rhGH treatment. Clinical and radiographic records were obtained at the initial, year 1, and year 2 visits. Tooth formation and stature were assessed by calculating Z-scores, appropriate for the age and gender of each child. Delta-Z scores, which measure the change in Z-score over time, were also calculated between annual visits. Height was measured and recorded every 3 months, and Z-score statural norms for age and gender were derived from the 1977 National Center for Health Services national probability sampling. Tooth formation standards were derived from Moorrees et al. A matched control sample for tooth development was derived from untreated children. Tooth formation was initially delayed although the degree of reduction in stature exceeded the initial degree of delay in tooth formation. During this 2-year study, rhGH therapy had a significant influence on acceleration or gain in stature, but did not have a significant influence on tooth formation.

Accurate prediction of postsurgical function and esthetics of the nose and upper lip requires an understanding of the relationship between maxillary surgical movement and soft tissue change. Thirty-two patients underwent Le Fort I osteotomies, some with concomitant mandibular procedures. Preoperative, postoperative, and 1-year postsurgical data derived from cephalometric and nasolabial cast analysis were compared to assess skeletodental changes, soft tissue changes, and stability. A multiple stepwise regression (including age, gender, alar cinch suture, V-Y closure, and contouring of the anterior nasal spine as variables) indicated that accurate prediction equations could be formulated, particularly if the patients were grouped by vector-specific maxillary movements. In general, the base of the nose widened in all patients regardless of the vector of surgical maxillary movement. An associated shortening of the nose was found. The nasolabial angle decreased or remained constant in most patients. The upper lip widened and lengthened at the philtral columns. Narrow noses widened more than did broad noses and alar cinch suturing widened the alar base even more. Results indicated that soft tissue changes associated with maxillary surgery may be more affected by the position of the soft tissue incision and methods used in closure than by the surgically induced hard tissue change.

The Dentofacial Deformity Program of the University of Michigan was established in 1984 to provide a consulting service for the diagnosis, treatment recommendations, and management of patients with dentofacial deformities. This program was designed as a service commitment for the patient, referring doctors, and the medical and dental communities. Educational and research aspects of the program provide benefits for orthodontic and oral and maxillofacial surgery graduate students, and the dental school faculty. The organization, data analysis, and education, research, and service benefits of this program are discussed.

The purpose of this study was to evaluate how incremental information obtained from different types of diagnostic records contributes to the determination of orthodontic treatment decisions. Pretreatment records of 57 orthodontic patients were assessed by five orthodontists who were part-time faculty members and also in private practice. This sample consisted of dental school orthodontic patients who had Class II malocclusions and included patients at three different dental developmental stages. The following diagnostic records were used: study models (S), facial photographs (F), a panoramic radiograph (P), a lateral cephalogram (C), and its tracing (T). Five combinations of diagnostic records were presented to the orthodontists in the following sequence: (1) S; (2) S + F; (3) S + F + P; (4) S + F + P + C; and (5) S + F + P + C + T. The simultaneous interpretation of all diagnostic records (S + F + P + C + T) was used as the "diagnostic standard." There was a diagnostic standard for each of the patients and for each of the orthodontists. The diagnostic standard was achieved: (1) S = 54.9%, (2) S + F = 54.2%, (3) S + F + P = 60.9%, and (4) S + F + P + C = 59.9%. Thus, in a majority of cases (55%), study models alone provided adequate information for treatment planning, and incremental addition of information from other types of diagnostic records made small differences.