Evaluation of facial asymmetry in patients with juvenile idiopathic arthritis: Correlation between hard tissue and soft tissue landmarks

Establishment of the mid-sagittal reference plane for three-dimensional assessment of facial asymmetry: a systematic review : Establishment of the mid-sagittal reference plane: a systematic review

OBJECTIVE

To systematically review the literature for mid-sagittal plane establishment approaches to identify the most effective method for constructing the mid-sagittal plane for the evaluation of facial asymmetry.

MATERIALS AND METHODS

Six electronic databases (PubMed, Medline (via Ovid), EMBASE (via Ovid), Cochrane Library, Web of Science, and Scopus) and grey literature were searched for the studies that computed the mid-sagittal reference plane three-dimensionally, using a combination of MeSH terms and keywords. The methodological quality and the level of evidence for the included studies were analyzed using QUADAS-2 and GRADE, respectively.

RESULTS

The preliminary search yielded 6746 records, of which 42 articles that met the predefined inclusion criteria were included in the final analysis. All the included articles reported the construction of the mid-sagittal reference plane (MSP) using varied methods. The risk of bias and concerns regarding the applicability of the included studies were judged to be 'low'. The level of evidence was determined to be 'low' for the effectiveness of the technique and 'moderate' for the ease of clinical applicability.

CONCLUSION

Despite methodological heterogeneity, this review substantiates the comparable efficacy of cephalometric and morphometric MSP construction methods. A fully automated morphometric MSP holds promise as a viable option for routine clinical use. Nevertheless, future prospective studies with an emphasis on the impact, accuracy, and clinical applicability of MSP construction techniques in cases of facial asymmetry are required.

CLINICAL RELEVANCE

The present review will assist clinicians in selecting the most suitable method for MSP construction, leading to improved treatment planning and ultimately more favorable treatment outcomes.

Long-Term Follow-Up of Orthognathic Surgery in 19 Patients with Juvenile Idiopathic Arthritis

Objectives

Dentofacial deformity following juvenile idiopathic arthritis with temporomandibular joint involvement is associated with functional, aesthetic, and psychosocial impairment. Surgical treatment may involve combinations of orthognathic surgery. The aims of this retrospective study were to assess orofacial symptoms, functional and aesthetic status, and stability after orthognathic surgery.

Material and Methods

Nineteen patients with juvenile idiopathic arthritis of the temporomandibular joint (TMJ) and dentofacial deformities were included. All patients were treated with combinations of bilateral sagittal split osteotomy, Le Fort I and/or genioplasty, between September 10, 2007 and October 17, 2017. Analysis of patient symptoms and clinical registrations, and frontal/lateral cephalograms was performed pre- and postoperative and long-term (mean: 3.8 and 2.6 years, respectively).

Results

Patients experienced no changes in orofacial symptoms or TMJ function, and stable normalisation of horizontal and vertical incisal relations at long-term (horizontal overbite; vertical overbite: P < 0.05). Mandibular lengthening was achieved postoperatively (from mean 79.7 to 87.2 mm; P = 0.004) and was stable. Sella-nasion to A point (SNA) and sella-nasion to B point (SNB) angles increased postoperatively (SNA, mean 79.9° to 82.8°; P = 0.022 and SNB, mean 73.9° to 77.8°; P = 0.003), however, largely reverted to preoperative status at long-term.

Conclusions

Orthognathic surgery normalized incisal relations while providing stable mandibular lengthening without long-term deterioration of temporomandibular joint function or orofacial symptoms. No long-term effect on jaw advancements was observed.

The effect of sex and age on facial shape directional asymmetry in adults: A 3D landmarks-based method study

OBJECTIVES

Facial directional asymmetry research, including age-related changes, is crucial for the evaluation of treatment of craniofacial malformations/trauma in orthodontics, facial surgery and forensic sciences. The aim was to describe facial directional asymmetry (DA) in different age categories of adults using 3D methods. According to our hypothesis, facial shape DA (1) depends on sex; (2) differs among age groups; and (3) has wider variability in older age.

MATERIAL AND METHODS

A cross-sectional sample of healthy Czech adults without craniofacial trauma or anomalies consisted of 300 3D facial models (151 females). The age-range in the study was between 20-80 years. The shape asymmetry of 28 3D landmarks was evaluated using geometric morphometrics and multivariate statistics.

RESULTS

The manifestation of DA was similar in both sexes and in each age category; however, there were some statistical differences. In contrast to the ideal symmetrical face, the mean asymmetrical faces tended to create a slightly bent "C" shape of the midline. Therefore, the upper face was rotated slightly clockwise and the lower face counter-clockwise. The right eye was located slightly higher, with the nasal tip and mandibular region tilting to the left. Sex differences in facial DA were significant before the age of 40. DA was more significant in the youngest males than in the oldest, while the women's DA did not change.

CONCLUSIONS

The DA patterns were similar in both sexes and in all age categories (a slightly bent C shape of the midline); however, some significant local differences between male age groups were found. A significantly more pronounced asymmetry compared to other age groups was found only in the youngest males from 20 to 40 years. Moreover, significant sexual dimorphism of DA rapidly decreased after middle age, likely caused by the same age-related changes of the face during aging.

A Novel and Simplified Parameter for Mandible Angle Asymmetry Evaluation in Chinese Females

AIM

To develop a novel and simplified parameter for mandible angle asymmetry (MAA) evaluation for facial countering surgeries in Chinese females.

MATERIALS AND METHODS

A total of 250 craniofacial computer tomography of healthy Chinese individuals were collected in this retrospective study. Mimics 21.0 was applied for 3-dimensional anthropometry. The Frankfort and Green planes were set as referenced vertical and horizontal planes for measuring the distances to gonions. The differences in both orientations were analyzed to verify the symmetry. Mandible angle asymmetry (∠Go-N-ANS, MAA) which comprehensively represented horizontal and vertical placements was defined qas the novel parameter for asymmetric evaluation and quantitative analysis was conducted to generate referenced materials.

RESULTS

Mandible angle asymmetry was divided into horizontal and vertical asymmetry. No significant differences were found in either horizontal or vertical orientations. The horizontal difference was 3.09±2.52 mm, the reference range was (0.28, 7.54) mm, whereas the±ertical difference was 2.59±2.48 mm, the reference range was (0.12, 6.34) mm. The difference of MAA was 1.74±1.30 degrees, and the reference range was (0.10,4.32）degrees.

CONCLUSION

This study provided a novel parameter for asymmetric evaluation in the mandible angle region through quantitative 3-dimensional anthropometry, arousing plastic surgeons' attention to both aesthetics and symmetry in facial contouring surgery.

Facial Asymmetry Detected with 3D Methods in Orthodontics: A Systematic Review

Background:

Historically, the development of two-dimensional (2D) imaging techniquesforerun that of three-dimensional (3D) ones. Some 2D methods are still considered valid and effective to diagnose facial asymmetry but 3D techniques may provide more precise and accurate measurements.

Objective:

The aim of this work is to analyze the accuracy and reliability of the imaging techniques available for the diagnosis of facial asymmetry in orthodontics and find the most reliable.

Methods:

A search strategy was implemented using PubMed (National Library of Medicine, NCBI).

Results:

A total of 3201 papers were identified in electronic searches. 90 articles, available in full text, were included in the qualitative synthesis consisting of 8 reviews on the diagnosis of facial asymmetry, 22 in vivo and in vitro studies on 2D methods and 60 in vivo and in vitro studies on 3D methods to quantify the asymmetry.

Conclusion:

2D techniques include X-ray techniques such as posterior-anterior cephalogram, which still represents the first level exam in the diagnosis of facial asymmetry. 3D techniques represent the second level exam in the diagnosis of facial asymmetry. The most current used techniques are CBCT, stereophotogrammetry, laser scanning, 3D optical sensors and contact digitization. The comparison between bilateral parameters (linear distances, angles, areas, volumes and contours) and the calculation of an asymmetry index represent the best choices for clinicians who use CBCT. The creation of a color-coded distance map seems to represent the most accurate, reliable and validated methods for clinicians who use stereophotogrammetry, laser scanning and 3D optical sensors.

Initial radiological signs of dentofacial deformity in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood and the temporomandibular joint (TMJ) is often involved. TMJ arthritis in growing individuals can cause deformation of facial skeleton (dentofacial deformity) and TMJ components (TMJ deformity). Treatment outcome hinges on early initiation of anti-inflammatory treatment and orthopaedic treatment with dental splints. The aim of the present study was to characterize the radiological signs of dentofacial deformity in patients with a JIA-induced need for orthopaedic treatment. We retrospectively studied 96 patients with JIA and 20 non-JIA controls to identify the initial radiological signs of JIA-induced dentofacial deformity leading to initiation of orthopaedic treatment. We found that initial radiological signs of dentofacial deformities were subtle and characterized by minor mandibular asymmetry and occlusal plane steepening. Radiological findings of TMJ deformity associated with initial dentofacial deformity were frequent and characterized by condylar articular surface flattening (OR 8.42), condylar subcortical cyst (OR 5.94), condylar surface erosion (OR 5.38) and condylar deviation in form (OR 25.39). Radiological signs of TMJ deformity were also documented in TMJs considered “healthy” during initial clinical and radiological examination. This study presents new knowledge of importance for early diagnosis of dentofacial deformity in JIA. Early diagnosis of dentofacial deformity is important as treatment outcome is greatly influenced by timely initiation.

The Relationship Between the Facial Proportion Changes in Hard Tissue and the Satisfaction of Patients After Reduction Malarplasty: a Research Based on Three-Dimensional Cephalometry

OBJECTIVE

We aim to measure the zygomatic width and protrusion changes in hard tissue after reduction malarplasty and then calculate facial proportion changes and analyze the relationship between facial proportion changes and patients' satisfaction.

METHODS

We retrospectively reviewed our database and selected 36 eligible patients who underwent isolated reduction malarplasty in our department from March 2015 to July 2018. The preoperative and postoperative facial width and protrusion, as well as head height, in hard tissue were measured using ProPlan software. Patients' satisfaction was evaluated by questionnaire. The correlations between the facial proportion changes and patients' satisfaction were analyzed using Spearman correlation analysis.

RESULTS

The preoperative and postoperative midface widths were 135.87 ± 4.09 mm and 129.06 ± 4.95 mm. The relative zygomatic protrusion was reduced by 3.29 ± 1.54 mm in the left and 2.88 ± 1.73 mm in the right after surgery. The ratio of the midface width to lower face width changed from 1.43 ± 0.05 to 1.36 ± 0.06 after surgery. And the ratio of the head height to midface width changed from 1.53 ± 0.05 to 1.61 ± 0.05 after surgery. The ratios were indeed close to the ideal ratios we presumed (4:3 and 1.618). Moreover, patients' total and morphology satisfaction were both significantly higher with the postoperative ratio of the midface width to lower face width closer to 4:3 (R = - 0.732, P < 0.001; R = - 0.906, P < 0.001, respectively). But only morphology satisfaction was higher with the ratio of the head height to midface width closer to 1.618 (R = - 0.404, P = 0.014) and the ratio of the postoperative midface to lower face width decreased (R = - 0.434, P = 0.008).

CONCLUSIONS

We found patients' morphology satisfaction was higher with the proportion of the postoperative midface to lower face width decreased. What's more, the proximity degree between the postoperative facial proportion and the ideal facial proportions we presumed was significantly correlated with patients' high satisfaction. Therefore, 4:3 and 1.618 may be the ideal postoperative facial ratios for the patients who underwent reduction malarplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266.

Cumulative Incidence of Orofacial Manifestations in Early Juvenile Idiopathic Arthritis: A Regional, Three-Year Cohort Study

OBJECTIVE

To estimate the cumulative incidence of arthritis-induced orofacial symptoms, dysfunction, and dentofacial deformities in growing individuals with juvenile idiopathic arthritis (JIA) in a 36-month regional cohort study and to identify predictors for the development of arthritis-induced dentofacial deformities.

METHODS

Data were retrieved from the Aarhus JIA temporomandibular joint (TMJ) cohort register, which contains standardized, longitudinal, observational data regarding orofacial conditions in patients with JIA (n = 1,040). This regional cohort represents the majority of all subjects with JIA from the western part of Denmark between 1990 and 2016, regardless of TMJ arthritis status. Cumulative incidences of orofacial conditions were reported using Kaplan-Meier methods, and predictors for dentofacial deformity were identified using Cox proportional hazards analysis.

RESULTS

Follow-up data from 351 subjects for 36 months were included in this study. Median age at first clinical examination was 6.6 years (interquartile range 4.8-9.9 years). Orofacial symptoms and dysfunctions were common findings at 36 months after the first clinical examination and 5 years after JIA onset, with a cumulative incidence of 38% and 53%, respectively. Dentofacial deformities were found in 35% of subjects at the 36-month follow-up and were significantly associated with the presence of orofacial dysfunction.

CONCLUSION

Orofacial conditions were frequently observed in individuals with JIA and were represented in all JIA subcategories in this regional study. One-third of subjects had arthritis-induced dentofacial deformities that required orthopedic appliance treatment at the 36-month follow-up.

Standardizing the Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: An Interdisciplinary, Consensus-based, Short Screening Protocol

OBJECTIVE

To develop a consensus-based, standardized, short (< 3 min) clinical examination protocol to assess the multidimensional, orofacial manifestations of juvenile idiopathic arthritis (JIA).

METHODS

The study was conducted by a multidisciplinary task force from the Temporomandibular Joint Juvenile Arthritis Working Group (TMJaw). The study used an acknowledged sequential approach involving (1) a global multidisciplinary online questionnaire study, (2) a systematic literature review and consensus meetings to identify items for inclusion, (3) pilot testing of included items, (4) test of reliability in 22 subjects with JIA by 4 examiners, (5) test of construct validity in a case-control study involving 167 subjects, and (6) establishment of final recommendations.

RESULTS

Six items were recommended for the final examination protocol: (1) clinician-assessed pain location, (2) temporomandibular (TMJ) joint pain on palpation (open and closed mouth), (3) mandibular deviation at maximal mouth opening (≥ 3 mm), (4) maximal unassisted mouth opening capacity, (5) frontal facial symmetry, and (6) facial profile. All recommended items showed acceptable reliability and construct validity. The average mean examination time was 2 min and 42 s (SD ± 38.5 s).

CONCLUSION

A consensus-based, short clinical examination protocol was developed. The protocol takes less than 3 min to complete and provides information about orofacial symptoms, TMJ dysfunction, and dentofacial deformity. The standardized examination protocol is applicable to routine clinical care, as well as future research studies.