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Wong DH, Rajan S, Hallett KB, Manton DJ. Medical and dental characteristics of children with chromosome 22q11.2 deletion syndrome at the Royal Children's Hospital, Melbourne. Int J Paediatr Dent 2021; 31:682-690. [PMID: 33222329 DOI: 10.1111/ipd.12755] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chromosome 22q11.2 deletion syndrome (22q11.2DS) is a multifaceted syndrome with a variable phenotype. Few studies have described the associated dental characteristics and their relationship with medical co-morbidities; and no Australian data exist. AIM To determine the clinical manifestations and correlations between oral and medical conditions in children with 22q11.2DS. DESIGN A retrospective observational study. Children genetically diagnosed with 22q11.2DS at the Royal Children's Hospital Melbourne were selected; their medical and dental characteristics were collated and analysed. RESULTS The study population (n = 57; mean age 11.5 years, range 2-27 years) experienced a range of medical conditions involving multiple medical systems; of whom 44 (77.2%) had caries experience, 7 (12.3%) developmentally missing teeth, and 31 (54.4%) developmental defects of enamel (DDE). Smaller proportions of primary teeth were affected by DDE in children with congenital heart disease (2.2% vs 9.7%; P = .02), and cardiac surgery (0.2% vs 9%; P = .001). Conversely, children with hypoparathyroidism (n = 2) had significantly higher proportions of primary teeth affected by DDE (27.5% vs 4%; P = .02). CONCLUSIONS Significant associations existed between medical conditions (congenital heart disease, history of cardiac surgery, and hypoparathyroidism) and primary dentition DDE in children with 22q11.2 DS.
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Affiliation(s)
- Deborah H Wong
- Paediatric Dentistry, Melbourne Dental School, The University of Melbourne, Melbourne, Vic., Australia.,The Royal Children's Hospital Melbourne, Melbourne, Vic., Australia
| | - Sadna Rajan
- Paediatric Dentistry, Melbourne Dental School, The University of Melbourne, Melbourne, Vic., Australia
| | - Kerrod B Hallett
- The Royal Children's Hospital Melbourne, Melbourne, Vic., Australia
| | - David J Manton
- Paediatric Dentistry, Melbourne Dental School, The University of Melbourne, Melbourne, Vic., Australia.,The Royal Children's Hospital Melbourne, Melbourne, Vic., Australia.,Centrum voor Tandheelkunde en Mondzorgkunde, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
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2
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Awadh W, Pegelow M, Heliövaara A, Rice DP. Dental age, agenesis, and morphological anomalies in individuals with Van der Woude syndrome and isolated cleft palate. Eur J Orthod 2021; 43:387-393. [PMID: 34079993 DOI: 10.1093/ejo/cjaa082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To analyse the differences between dental age and chronological age and dental anomalies in individuals with Van der Woude syndrome (VWS) and compare with non-syndromic cleft palate (NSCP) and non-cleft controls. MATERIALS AND METHODS In total, 204 oral panoramic radiographs (118 girls and 86 boys) consisting of 51 VWS patients (age x̅ = 8.17 ± 1.34 years), 51 NSCP patients (age x̅ = 8.09 ± 1.41 years), and 102 normative non-cleft children (age x̅ = 8.62 ± 1.24 years) were collected. Dental stages were assessed by the Demirjian method, with the local dental maturity index as reference. Dental anomalies including agenesis were investigated. Statistical differences were determined by One-way ANOVA and regression. Repeatability was calculated by an intra-class correlation test and 95% confidence interval. RESULTS The difference between dental age and chronological age of the VWS group (0.12 years) and the NSCP group (0.09 years) was significantly lower than the non-cleft group (0.40 years) (P = 0.002). There was no significant difference between the VWS and NSCP groups (P = 0.885). Hypodontia was more prevalent in both the VWS group (37.25%, P = 0.0001) and the NSCP group (19.60%, P = 0.035) compared with the non-cleft group (5.88%). The odds for hypodontia in the VWS group were approximately double compared with the NSCP group. In VWS patients, the most commonly missing teeth were the permanent second premolars and the maxillary permanent laterals incisors. Peg-shaped teeth had a prevalence of 13.70% in VWS patients. CONCLUSIONS In VWS and NSCP patients compared with non-cleft children, the difference in dental age compared with chronological age decreased. Hypodontia occurs at a high prevalence in VWS and NSCP patients compared with non-cleft children.
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Affiliation(s)
- Wael Awadh
- Department of Oral and Maxillofacial Diseases, Division of Orthodontics, University of Helsinki and Helsinki University Hospital, Finland.,Department of Dental Medicine, Division of Orthodontics, Karolinska Institutet, Stockholm, Sweden.,Department of Preventive Dental Sciences, Division of Orthodontics, College of Dentistry, Jazan University, Saudi Arabia
| | - Marie Pegelow
- Department of Dental Medicine, Division of Orthodontics, Karolinska Institutet, Stockholm, Sweden
| | - Arja Heliövaara
- Department of Plastic Surgery, Cleft Palate and Craniofacial Center, Helsinki University Hospital, Finland
| | - David P Rice
- Department of Oral and Maxillofacial Diseases, Division of Orthodontics, University of Helsinki and Helsinki University Hospital, Finland
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3
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De Santis D, Sinigaglia S, Faccioni P, Pancera P, Luciano U, Bertossi D, Lucchese A, Albanese M, Nocini PF. Syndromes associated with dental agenesis. ACTA ACUST UNITED AC 2019; 68:42-56. [PMID: 30667203 DOI: 10.23736/s0026-4970.18.04129-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Dental agenesis is the congenital absence of a variable number of teeth due to the lack of formation of the corresponding tooth germ. The aim of this work was to investigate the syndromic conditions characterized by dental agenesis. EVIDENCE ACQUISITION Based on the research conducted through the OMIM® (Online Mendelian Inheritance in Man) and PubMed online databases, more than ninety syndromes associated with severe or moderate agenesis have been found. EVIDENCE SYNTHESIS The main clinical features of these syndromes are described, especially those concerning the stomatognathic apparatus, referring to the most recent literature. Among these syndromes there are three clinical conditions associated with dental agenesis that are common for the clinician: Down Syndrome, ectodermal dysplasia and labio-palatal cleft. CONCLUSIONS It must be kept in mind that the success of the treatment of these patients is based on the compliance of the patient as well as on the collaboration among specialists.
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Affiliation(s)
- Daniele De Santis
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Stefano Sinigaglia
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy -
| | - Paolo Faccioni
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Paola Pancera
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Umberto Luciano
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Dario Bertossi
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Alessandra Lucchese
- Department of Orthodontics, Vita Salute San Raffaele University, Milan, Italy.,Unit of Dentistry, Division of Orthodontics, Research Area in Dentofacial Orthopedics and Orthodontics, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Albanese
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Pier Francesco Nocini
- Section of Oral and Maxillofacial Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
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4
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AlQarni MA, Alharbi A, Merdad L. Dental management of a patient with 22q11.2 deletion syndrome (22q11.2DS). BMJ Case Rep 2018; 2018:bcr-2018-225765. [PMID: 30232069 DOI: 10.1136/bcr-2018-225765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
22q11.2 deletion syndrome (22q11.2DS) is one of the most common microdeletion syndromes, with an incidence of approximately 1/2000-1/4000 live births; it is thought to be mainly attributable to a de novo deletion. The clinical phenotype of this syndrome is highly variable. Certain craniofacial and oral features are common to most patients with 22q11.2DS, including a high prevalence of dental caries; abnormalities of tooth shape, eruption and number; and enamel defects such as hypomineralisation and hypoplasia. This report focuses on the dental features and management of an 8-year-old boy with 22q11.2DS. Dental treatments were carried out under general anaesthesia. In summary, facial dysmorphism and common dental manifestations are typically noticeable in patients with this syndrome. Therefore, dentists need to be aware of the dental features of this condition in order to refer them to the adequate specialists. Cooperation among and experience with different specialties are mandatory to improve quality of life for patients with 22q11.2DS.
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Affiliation(s)
| | - Adel Alharbi
- Paediatric Dentistry Department, Al Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Leena Merdad
- Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
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Hejlesen J, Underbjerg L, Gjørup H, Bloch-Zupan A, Sikjaer T, Rejnmark L, Haubek D. Dental Findings in Patients With Non-surgical Hypoparathyroidism and Pseudohypoparathyroidism: A Systematic Review. Front Physiol 2018; 9:701. [PMID: 29971010 PMCID: PMC6018410 DOI: 10.3389/fphys.2018.00701] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Dental aberrations have been mentioned in relation to non-surgical hypoparathyroidism (Ns-HypoPT) and pseudohypoparathyroidism (PHP). However, a systematic review of dental characteristics have not been performed. The present systematic review describes the dental findings in patients with Ns-HypoPT and PHP. Methods: Studies on Ns-HypoPT and PHP reporting dental features were eligible. A systematic literature search was conducted using four bibliographic databases (Web of Science, Scopus, Pubmed, and Embase) and was limited to studies written in English. Reviews, meta-analyses and letters were excluded. Both the research and reporting of results were based on PRISMA (preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Results: Of 88 studies included, nine were cross-sectional, one was a prospective cohort study, 26 were case series, and 52 were case reports. The most frequently reported findings in patients with Ns-HypoPT were enamel opacities, enamel hypoplasia, hypodontia, and eruption disturbances. In patients with PHP, enamel hypoplasia, eruption disturbance, and deviation of the root morphology were the most frequently reported findings. Conclusion: An association between enamel hypoplasia and Ns-HypoPT and PHP is likely. The results should, however, be interpreted cautiously due to the limited number of high-quality studies. The present review confirms the need of further well-designed studies, such as large-scale studies, e.g., multicenter studies, to conclude on the reported associations between Ns-HypoPT/PHP and enamel hypoplasia.
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Affiliation(s)
- Jane Hejlesen
- Section for Pediatric Dentistry, Department of Dentistry and Oral Health, Health, Aarhus University, Aarhus, Denmark
| | - Line Underbjerg
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Gjørup
- Center for Oral Health in Rare Diseases, Department of Maxillofacial Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Agnes Bloch-Zupan
- Faculté de Chirurgie Dentaire, Institut d'Etudes Avancées, USIAS, FMTS, RARENET Interreg V, Université de Strasbourg, Strasbourg, France.,Pôle de Médecine et Chirurgie Bucco-Dentaires, Centre de Référence des Maladies Rares Orales et Dentaires, O-Rares, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire and Cellulaire, Centre Européen de Recherche en Biologie et en Médecine, Université de Strasbourg, Centre National de la Recherche Scientifique UMR7104, Institut National de la Santé et de la Recherche Médicale U964, Illkirch, France
| | - Tanja Sikjaer
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Dorte Haubek
- Section for Pediatric Dentistry, Department of Dentistry and Oral Health, Health, Aarhus University, Aarhus, Denmark
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6
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Bartzela TN, Carels C, Maltha JC. Update on 13 Syndromes Affecting Craniofacial and Dental Structures. Front Physiol 2017; 8:1038. [PMID: 29311971 PMCID: PMC5735950 DOI: 10.3389/fphys.2017.01038] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/29/2017] [Indexed: 12/12/2022] Open
Abstract
Care of individuals with syndromes affecting craniofacial and dental structures are mostly treated by an interdisciplinary team from early childhood on. In addition to medical and dental specialists that have a vivid interest in these syndromes and for whom these syndromes are of evident interest, experts of scientific background-like molecular and developmental geneticists, but also computational biologists and bioinformaticians-, become more frequently involved in the refined diagnostic and etiological processes of these patients. Early diagnosis is often crucial for the effective treatment of functional and developmental aspects. However, not all syndromes can be clinically identified early, especially in cases of absence of known family history. Moreover, the treatment of these patients is often complicated because of insufficient medical knowledge, and because of the dental and craniofacial developmental variations. The role of the team is crucial for the prevention, proper function, and craniofacial development which is often combined with orthognathic surgery. Although the existing literature does not provide considerable insight into this topic, this descriptive review aims to provide tools for the interdisciplinary team by giving an update on the genetics and general features, and the oral and craniofacial manifestations for early diagnosis. Clinical phenotyping together with genetic data and pathway information will ultimately pave the way for preventive strategies and therapeutic options in the future. This will improve the prognosis for better functional and aesthetic outcome for these patients and lead to a better quality of life, not only for the patients themselves but also for their families. The aim of this review is to promote interdisciplinary interaction and mutual understanding among all specialists involved in the diagnosis and therapeutic guidance of patients with these syndromal conditions in order to provide optimal personalized care in an integrated approach.
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Affiliation(s)
- Theodosia N Bartzela
- Department of Orthodontics, Dentofacial Orthopedics and Pedodontics, Charité-Universitätsmedizin, Berlin, Germany.,Department of Orthodontics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Carine Carels
- Department of Oral Health Sciences, KU Leuven, Leuven, Belgium
| | - Jaap C Maltha
- Department of Orthodontics and Craniofacial Biology, Radboud University Medical Center, Nijmegen, Netherlands
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7
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Lewyllie A, Roosenboom J, Indencleef K, Claes P, Swillen A, Devriendt K, Carels C, Cadenas De Llano-Pérula M, Willems G, Hens G, Verdonck A. A Comprehensive Craniofacial Study of 22q11.2 Deletion Syndrome. J Dent Res 2017; 96:1386-1391. [PMID: 28732176 DOI: 10.1177/0022034517720630] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The 22q11.2 deletion syndrome (22q11.2DS) is one of the most frequent microdeletion syndromes and presents with a highly variable phenotype. In most affected individuals, specific but subtle facial features can be seen. In this observational study, we aim to investigate the craniofacial and dental features of 20 children with a confirmed diagnosis of 22q11.2DS by analyzing 3-dimensional (3D) facial surface scans, 2-dimensional (2D) clinical photographs, panoramic and cephalometric radiographs, and dental casts. The 3D facial scans were compared to scans of a healthy control group and analyzed using a spatially dense geometric morphometric approach. Cephalometric radiographs were digitally traced, and measurements were compared to existing standards. Occlusal and dental features were studied on dental casts and panoramic radiographs. Interestingly, a general trend of facial hypoplasia in the lower part of the face could be evidenced with the 3D facial analysis in children with 22q11.2DS compared to controls. Cephalometric analysis confirmed a dorsal position of the mandible to the maxilla in 2D and showed an enlarged cranial base angle. Measurements for occlusion did not differ significantly from standards. Despite individual variability, we observed a retruded lower part of the face as a common feature, and we also found a significantly higher prevalence of tooth agenesis in our cohort of 20 children with 22q11.2DS (20%). Furthermore, 3D facial surface scanning proved to be an important noninvasive, diagnostic tool to investigate external features and the underlying skeletal pattern.
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Affiliation(s)
- A Lewyllie
- 1 Department of Oral Health Sciences - Orthodontics, KU Leuven & Dentistry, University Hospitals Leuven, Leuven, Belgium
| | - J Roosenboom
- 2 Department of Neurosciences, Experimental Otorhinolaryngology, KU Leuven, Leuven, Belgium
| | - K Indencleef
- 3 Medical Image Computing, ESAT/PSI, Department of Electrical Engineering, KU Leuven, Medical Imaging Research Center, Leuven, Belgium
| | - P Claes
- 3 Medical Image Computing, ESAT/PSI, Department of Electrical Engineering, KU Leuven, Medical Imaging Research Center, Leuven, Belgium
| | - A Swillen
- 4 Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - K Devriendt
- 4 Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - C Carels
- 1 Department of Oral Health Sciences - Orthodontics, KU Leuven & Dentistry, University Hospitals Leuven, Leuven, Belgium
| | - M Cadenas De Llano-Pérula
- 1 Department of Oral Health Sciences - Orthodontics, KU Leuven & Dentistry, University Hospitals Leuven, Leuven, Belgium
| | - G Willems
- 1 Department of Oral Health Sciences - Orthodontics, KU Leuven & Dentistry, University Hospitals Leuven, Leuven, Belgium
| | - G Hens
- 5 Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven, Leuven, Belgium
| | - A Verdonck
- 1 Department of Oral Health Sciences - Orthodontics, KU Leuven & Dentistry, University Hospitals Leuven, Leuven, Belgium
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8
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Tooth agenesis and orofacial clefting: genetic brothers in arms? Hum Genet 2016; 135:1299-1327. [PMID: 27699475 PMCID: PMC5065589 DOI: 10.1007/s00439-016-1733-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 09/21/2016] [Indexed: 12/16/2022]
Abstract
Tooth agenesis and orofacial clefts represent the most common developmental anomalies and their co-occurrence is often reported in patients as well in animal models. The aim of the present systematic review is to thoroughly investigate the current literature (PubMed, EMBASE) to identify the genes and genomic loci contributing to syndromic or non-syndromic co-occurrence of tooth agenesis and orofacial clefts, to gain insight into the molecular mechanisms underlying their dual involvement in the development of teeth and facial primordia. Altogether, 84 articles including phenotype and genotype description provided 9 genomic loci and 26 gene candidates underlying the co-occurrence of the two congenital defects: MSX1, PAX9, IRF6, TP63, KMT2D, KDM6A, SATB2, TBX22, TGFα, TGFβ3, TGFβR1, TGFβR2, FGF8, FGFR1, KISS1R, WNT3, WNT5A, CDH1, CHD7, AXIN2, TWIST1, BCOR, OFD1, PTCH1, PITX2, and PVRL1. The molecular pathways, cellular functions, tissue-specific expression and disease association were investigated using publicly accessible databases (EntrezGene, UniProt, OMIM). The Gene Ontology terms of the biological processes mediated by the candidate genes were used to cluster them using the GOTermMapper (Lewis-Sigler Institute, Princeton University), speculating on six super-clusters: (a) anatomical development, (b) cell division, growth and motility, (c) cell metabolism and catabolism, (d) cell transport, (e) cell structure organization and (f) organ/system-specific processes. This review aims to increase the knowledge on the mechanisms underlying the co-occurrence of tooth agenesis and orofacial clefts, to pave the way for improving targeted (prenatal) molecular diagnosis and finally to reflect on therapeutic or ultimately preventive strategies for these disabling conditions in the future.
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9
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Ginzelová K, Dostálová T, Eliášová H, Vinšů A, Buček A, Bučková M. Using Dental Age to Estimate Chronological Age in Czech Children Aged 3-18 Years. Prague Med Rep 2015; 116:139-54. [PMID: 26093668 DOI: 10.14712/23362936.2015.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The Demirjian methods to determine dental age are based on analysis of orthopantograms. The dental age estimation is based on establishing the tooth development stages. The purpose of this study was to assess the accuracy of estimation of dental age by Demirjian in the use of all of his four methods. 505 Czech healthy boys and girls aged 3 to 18 years were examined radiographically at the Department of Stomatology, Second Faculty of Medicine, Charles University in Prague. It was mentioned the factors of underlying diseases influence the accuracy of the dental age estimation. For statistical evaluation, descriptive statistics was used to compare deviations of the mean values of chronological and dental age in each age group. The resulting difference between dental age and chronological age is not significant in both genders only when using both Demirjian 7-teeth methods of 1973 and 1976. Therefore these may be most appropriately used for forensic age estimation. There are shown standard deviation differences in different countries. Demirjian's original 7-teeth method from 1973 and Demirjian's revised 4-teeth method from 1976 appear to be the best methods for calculating the dental age of healthy Czech children of both genders.
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Affiliation(s)
- Kristina Ginzelová
- Department of Stomatology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Taťjana Dostálová
- Department of Stomatology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic.
| | | | - Alex Vinšů
- Department of Stomatology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Antonín Buček
- Department of Stomatology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Michaela Bučková
- Department of Stomatology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic
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