THESIS – SYNOPSIS
DR.SHARAD KHARYAL
POST GRADUATE STUDENT
DEPARTMENT OF ORTHODONTICS AND
DENTOFACIAL ORTHOPAEDICS
K.V.G. DENTAL COLLEGE & HOSPITAL
KURUNJIBAGH, SULLIA – 574327
DAKSHINA KANNADA
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / : / DR. SHARAD KHARYALPOST GRADUATE STUDENT,
DEPT OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS,
K.V.G DENTAL COLLEGE & HOSPITAL,
KURUNJIBAGH, SULLIA – 574 327
2. /
NAME OF THE INSTITUTION
/ : / K.V.G. DENTAL COLLEGE & HOSPITAL,KURUNJIBAGH, SULLIA – 574 327.
3. / COURSE OF THE STUDY AND SUBJECT / : / MASTER OF DENTAL SURGERY
ORTHODONTICS, BRANCH –V
4. / DATE OF ADMISSION TO COURSE / : / 05-06-2013
5. / TITLE OF THE TOPIC / : / COMPARISON OF VISUAL CLASSIFICATION ON PROFILE PHOTOGRAPHS AND LATERAL CEPHALOMETRIC ANALYSIS FOR ASSESSMENT OF ANTERIOR MALAR PROJECTION IN DAKSHINA KANNADA POPULATION.
6.
7.
8. / BRIEF RESUME OF THE INTENDED STUDY
6.1 Need for the Study
The clinical ability to alter dentofacial form requires an understanding of facial esthetics. Inspite of the role of the midface in facial esthetics, there is a shortage of diagnostic criteria in orthodontic literature. 1
The orbital rim and cheek bone contour correlates with maxillary hypoplasia which is often associated with true malar deficiency2,3 but there are very few readily available methods for making accurate, reproducible measurements of orbital relationships. In addition, due to difficulty in assessing skeletal structures of midface in lateral cephalogram, orthodontists focus entirely on premaxilla which results in neglection of regional disharmonies in the anatomy of the maxilla.1
The relationship of anterior cheek mass to the anterior corneal plane has been used in esthetic blepharoplasty as an indicator of bony support along the malar eminence.1,4 The ideal position of the cheek prominence should be 2mm beyond the anterior surface of the cornea in the sagittal plane along the Frankfort horizontal.1,5
Maxillary hypoplasia in this region produces a negative vector relationship with the globe positioned anterior to malar eminence.1,4,5 Though it is widely used, the validity of the relationship between maxillary development and vector relationships has not been tested widely.
A recent study done in white subjects for the clinical assessment of anterior malar projection showed significant relationship between cephalometric analysis and visual classification of anterior malar projection.1 This relationship has not been studied for other ethnic groups. Hence, this study will be undertaken to assess the relationship between visual classification and lateral cephalometric analysis of anterior malar projection in Dakshina Kannada population.
6.2 Review of the Literature
A study was done for analysis of craniofacial morphology and growth. Powerful mathematical tools were applied to describe and analyze morphologic structures by developing models to represent craniofacial bones. In this study, a total set of 177 points were used to describe the skull. This approach contained information related to size , shape, and relative positions of all the profile elements and also described the growth dynamics of the entire face and cranium and the information could be provided pretreatment, during treatment and post treatment.8
A study was conducted on the influence of orbital and eyelid anatomy on the palpebral aperture. It was reported that a multitude of factors influenced the palpebral aperture: the surrounding bony orbital anatomy, the internal orbital volume, the integrity of the eyelids and their muscular and tarsoligamentous support system. Furthermore, it was found that the relative amount of associated periorbital skin, fat and soft tissues also influenced the orbital anatomy and the unique individual combinations of the above eyelid and orbital anatomic influences caused the variations in the palpebral apertures.4
A study was done to present an organized, comprehensive clinical facial analysis and to discuss the soft tissue changes associated with orthodontic and surgical treatments of malocclusion. It was reported that typical facial keys used by orthodontists included relative positions of the upper lip, lower lip, and chin and four possible treatments for each patient were also reported: (i) orthodontics alone, (ii) orthodontics plus lower jaw surgery, (iii) orthodontics plus upper jaw surgery and (iv) orthodontics plus both upper and lower jaw surgery. The treatment that optimized occlusion, facial balance, stability and periodontal health was chosen.2,3
A study was done on the concept of the sagittal orbital-globe relationship in craniofacial surgery. The normal values of four soft tissue landmarks: orbitale superius(os), orbitale inferius(oi), orbitale lateral(ol) and nasion(n) were extracted from the literature for the sagittal orbital globe relationship. A vernier caliper was used to measure preoperatively the surface orbital landmarks in patients with syndromic and non-syndromic craniosynostotic disorders and those measurements were compared with the derived normative data to determine the necessary sagittal orbital translocation for frontal and frontal-midfacial sagittal advancement. Postoperative orbital anthropometry documented the degree of normalization of the sagittal orbital-globe relationship.10
A study was conducted to initiate a new soft tissue cephalometric analysis tool including 46 adult white models with class I occlusions which were assessed clinically in natural head position, seated condyles, and with passive lips. This analysis could be used by the orthodontist and surgeon as an aid in diagnosis and treatment planning. The novelty of this approach, as with the “Facial keys” articles, was an emphasis on soft tissue facial measurement.9
A study was conducted on infraorbital rim augmentation in patients with recessive infraorbital rims. In this study, the cheek prominence beyond the anterior surface of cornea was termed as positive vector and the cheek prominence behind the anterior surface of cornea was termed as negative vector. Ten patients (7 women and 3 men) with an average age of 30 years underwent augmentation of the infraorbital rim with alloplastic implants over a 9-year period with an average follow up of 3 years. Results showed that reconstructions remained stable and satisfactory with no incidence of infection, infraorbital nerve damage or palpebral fissure distortion and concluded that the alloplastic infraorbital rim augmentation could normalize their globe-infraorbital rim relationship and improve their appearence.5
A study was done to compare the 3-dimensional (3-D) effects on the face of extraction and non-extraction orthodontic treatment in 24 patients which included 12 whose treatment included extractions and 12 who were treated without extractions. Pretreatment and post treatment lateral cephalograms and optical surface scans were also compared. Results of the study showed that at the end of the treatment, the non-extraction group showed more convex cheeks and in extraction group, the lower part of the cheeks showed a gradual flattening.6
A study was done to review retrospectively 150 patients who underwent surgical mid-face rejuvenation. Physical examination and photography were used to classify patients. The results of the study found that dissatisfaction rates were significantly higher with malar hypoplasia and unsatisfactory results were most common when mid-facial aging was accompanied by skeletal insufficiency.7
A study was conducted to determine whether a visual classification of anterior malar support using vector relationships was supported by cephalometric analysis. The study included 40 white subjects between the ages 10-12 years, without craniofacial syndromes or previous orthodontic treatments which were equally divided into two groups based on visual assessment of negative and positive vector relationship. The results of the study showed that there was no statistically significant difference between genders. SNO angulations in the negative vector group were smaller than the positive vector controls by an average of 6.0 degrees, and the difference was highly significant.1
6.3 Objectives of the Study
1. To estimate the anterior malar projection using visual classification on profile photographs.
2. To estimate the anterior malar projection using lateral cephalograms.
3. To compare the relationship between visual classification on profile photographs and lateral cephalometric analysis of anterior malar projection in Dakshina Kannada population.
MATERIALS & METHODS
7.1 Source of Data
Pretreatment records of 100 subjects native to Dakshina Kannada seeking orthodontic treatment in K.V.G. Dental College and Hospital, Sullia will be included in the study. The subjects will be equally divided into two groups of 50 each based on visual assessment of negative and positive vector relationships.
Group A will include 50 subjects (25 males, 25 females) exhibiting a positive vector relationship.
Group B will include 50 subjects (25 males, 25 females) exhibiting a negative vector relationship.
Age group: 15-25 years.
Duration of study: 18-20 months.
7.2 Method of Collection of Data
Pretreatment records of 100 subjects native to Dakshina Kannada seeking orthodontic treatment in K.V.G. Dental College and Hospital, Sullia will be included in the study.
Inclusion criteria:
1. Good quality lateral cephalograms.
2. Good quality profile photographs.
3. Patients in age group: 15-25 years.
4. No history of craniofacial trauma.
5. No ophthalmic problems.
Exclusion criteria:
1. Previous orthodontic treatment.
2. Craniofacial syndromes.
3. History of maxillofacial or plastic surgery.
Materials Required:
1. Pretreatment Standardized Lateral Cephalometric radiographs.
2. Pretreatment Profile Photographs.
3. SLR camera (Cannon 600D, macro lens 18mm-55mm).
Methodology:
Lateral cephalograms and profile photographs standardized by orienting the patient’s head in the Frankfort horizontal position will be obtained from the patient’s pretreatment records. Each subject’s vector relationship will be determined by one operator, using only pretreatment profile photographs.
For the purpose of this study, if the cheek prominence is behind the anterior surface of cornea, it will be considered as negative vector relationship while if the cheek prominence is beyond the anterior surface of cornea, it will be considered as positive vector relationship.
Lateral cephalogram will be traced manually and the reference points will be marked.
Reference points of the cephalograms:
S - Sella turcica ( The midpoint of sella turcica)
N - Nasion ( The intersection of the internasal suture with nasofrontal suture in the mid sagittal plane)
O - Orbitale (According to Walker GF- Walker’s cephalogram point 109.)
In order to quantify skeletal support for each subject, sella-nasion-orbitale (SNO) angulations will be used to evaluate the anteroposterior position of the malar eminence relative to the cranial base.
Error estimation:
Prior to the cephalometric analysis, 15 random lateral cephalograms from subjects in the study will be selected, and SNO angles will be traced and measured at two times. The intraclass correlation coefficients will be calculated to estimate the intraobserver agreement.
Statistical Analysis
Statistical analysis will be done using SPSS software version 20 (SPSS Inc., Chicago, IL, USA). Descriptive statistics will be computed for angular measurements of Group A males and females, and Group B males and females. Gender differences will be examined using Mann-Whitney U-tests.
Descriptive statistics will be calculated for angular measurements of Group A and Group B, and significant differences between SNO measurements for Group A and B will be assessed using Mann-Whitney U-tests.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED IN PATIENTS OR OTHER HUMANS
NO, this study will use the pretreatment cephalometric radiographs and profile photographs of the patients from the records.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION
YES. Institutional Ethics Committee clearance enclosed.
LIST OF REFERENCES
1. Frey ST. New diagnostic tenet of the esthetic midface for clinical assessment of anterior malar projection. Angle Orthod 2013;83:790-794.
2. Arnett G. Facial keys to orthodontic diagnosis and treatment planning, part I. Am J Orthod Dentofacial Orthop 1993;103:299-312.
3. Arnett G, Bregman R. Facial keys to orthodontic diagnosis and treatment planning, part II. Am J Orthod Dentofacial Orthop 1993;103:395-411.
4. Jelks G. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg 1991;18:183-195.
5. Yaremchuk M. Infraorbital rim augmentation. Plast Reconstr Surg 2001;107:1585-1592.
6. Ismail SFH, Moss JP, Hennessy R. Three-dimensional assessment of the effects of extraction and nonextraction orthodontic treatment on the face. Am J Orthod Dentofacial Orthop 2002;121:244-256.
7. Jacono AA, Ransom ER. Anatomic Predictors of Unsatisfactory Mid-Face Surgical Rejuvenations. JAMA Facial Plast Surg 2013;15:101-109.
8. Walker GF. A new approach to the analysis of craniofacial morphology and growth. Am J Orthod Dentofacial Orthop 1972;61:221-230.
9. Arnett G, Jelic J, Kim J, Cummings D. Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial Orthop 1999;116:239-253.
10. Mulliken JB, Godwin SL, Pracharktam N, Altobelli DE. The concept of the sagittal orbital-globe relationship in craniofacial surgery. Plast Reconstr Surg 1996;97:700-706.
9. / SIGNATURE OF CANDIDATE
10. /
REMARKS OF THE GUIDE
11. / NAME AND DESIGNATION OF11.1 GUIDE / DR. MAHESH KUMAR Y, M.D.S.
PROFESSOR,
DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS,
K.V.G DENTAL COLLEGE AND HOSPITAL, KURUNJIBAGH, SULLIA, D.K -574327
11.2 SIGNATURE
11.3 HEAD OF THE DEPARTMENT / DR. SHARATH KUMAR SHETTY, M.D.S.
DIRECTOR OF PG STUDIES,
PROFESSOR AND HOD,
DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS,
K.V.G DENTAL COLLEGE AND HOSPITAL, KURUNJIBAGH, SULLIA, D.K -574327
11.4 SIGNATURE
12. /
REMARKS OF THE PRINCIPAL
DR. MOKSHA NAYAK, M.D.S.PRINCIPAL,
K.V.G. DENTAL COLLEGE AND HOSPITAL, KURUNJIBAGH, SULLIA.
12.1 SIGNATURE