Cost-minimization analysis of conventional fixed appliances in comparison with Invisalign System

Due to the high prevalence of malocclusion and social disparity existent in Brazil, orthodontic procedures, such as corrective orthodontic treatments with fixed appliances (FA) need to be incorporated into the Unified Health System (SUS). However, Invisalign System (IS) have been developed to perform satisfactory esthetic orthodontic treatment. This new approach raises questions about the economic feasibility of orthodontic treatment in the public services. Objective/methodology: cost-minimization economic evaluation was carry by microcosting (down-top) of direct medical costs for the two treatment options. Results: The treatment with the conventional fixed appliance (FA) was R$2,214.60, and for the Invisalign System (IS) the treatment cost was R$ 5.934,52, for the treatment of Class I and II of Angle with low crowding. Conclusion: In terms of cost, the Invisalign System is a more expensive. Meanwhile, is imperative for the public services to evaluate economic resources and clinical benefits such as clinical time consumed, patient capacity, and number of maintenance appointments required during orthodontic treatment. Therefore, another alternative as “in office” aligners manufactured by orthodontists could be consider as a cheaper, and better option for public services

Aesthetic and functional rehabilitation of anterior teeth after trauma: a case report

Traumatic dental injuries are common clinical problems during childhood, and may have complex etiologies causing physical and physiological impairment. The aim of this study was to report the management of a severe traumatic dental injury in an 8-year-old female patient, victim of a motorcycle accident, who was taken to a pediatric dentistry clinic three months after the accident. After clinical and radiografic examination, we observed the avulsion of the permanent maxillary central incisors and of the permanent left lateral incisor, with considerable lingual interposition, interfering in speech and swallowing. The patient showed low risk of caries and good behavior during the appointments. However, she demonstrated to be embarrassed to smile. Besides the preventive treatment concerning caries, the treatment plan included immediate care and subsequent monitoring of the psychosocial reestablishment. For this purpose, an acrylic partial denture was made in order to replace the missing anterior teeth, maintaining the characteristics of the mixed dentition and preserving the aesthetics and the function. Follow-up appointments were performed one, three and six months after the first visit, aiming to monitor the adaptation of the prosthesis, as well as the growth and development of the child’s dentition. Thus, the aesthetic and functional rehabilitation was achieved regarding the patient’s satisfaction, enabling immediate social reinsertion.Lesões dentárias traumáticas são problemas clínicos comuns durante a infância e podem ter etiologias complexas, causando deficiências físicas e fisiológicas. O objetivo deste estudo foi relatar um caso de lesão dentária traumática grave em uma paciente de 8 anos de idade, vítima de um acidente de moto, que foi levada para uma clínica de odontopediatria três meses depois do acidente. Exames clínicos e radiológicos diagnosticaram a avulsão dos incisivos centrais superiores permanentes, do incisivo lateral esquerdo permanente e do canino esquerdo decíduo, com considerável interposição da língua, interferindo na fala e deglutição. A paciente apresentou baixo risco de cárie e bom comportamento durante as consultas. No entanto, ela demonstrou estar envergonhada para sorrir. Além do tratamento preventivo para a cárie, o plano de tratamento incluiu atendimento imediato e acompanhamento posterior do restabelecimento psicossocial da paciente. Para este efeito, uma prótese parcial acrílica foi feita para substituir os dentes anteriores que faltavam, mantendo as características da dentição mista e preservando sua estética e função. Consultas de acompanhamento foram realizadas em um, três e seis meses após a primeira visita, com o objetivo de monitorar a adaptação da prótese, bem como o crescimento e desenvolvimento da dentição da criança. Assim, a reabilitação estética e funcional foi alcançada considerando a satisfação da paciente, permitindo sua reinserção social imediata

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Evaluation of enamel surface after bracket debonding and polishing Avaliação da superfície do esmalte dentário após a remoção do braquete e polimento

INTRODUCTION: Preserving the dental enamel structure during removal of orthodontic accessories is a clinician's obligation. Hence the search for an evidence based debonding protocol. OBJECTIVE: to evaluate and compare, by means of scanning electron microscopy (SEM), the effects of four different protocols of bracket debonding and subsequent polishing on enamel surface, and to propose a protocol that minimizes damage to enamel surface. METHODS: Twelve bovine permanent incisors were divided into four groups according to the instrument used for debonding and removal of the adhesive remnant. In groups 1 and 2, brackets were debonded with a straight debonding plier (Ormco Corp., Glendora, California, USA), and in groups 3 and 4, debonding was performed with the instrument Lift-Off (3M Unitek, Monrovia, California, USA). In groups 1 and 3, the adhesive remnant was removed using a long adhesive removing plier (Ormco Corp., Glendora, California, USA) and in groups 2 and 4, residual adhesive was removed with a tungsten carbide bur (Beavers Dental) at high-speed. After each stage of debonding and polishing, enamel surfaces were replicated and electron micrographs were obtained with 50 and 200X magnification. RESULTS: All four protocols of debonding and polishing caused enamel irregularities. CONCLUSION: Debonding brackets with straight debonding plier, removal of adhesive remnant with a tungsten carbide bur and polishing with pumice and rubber cup was found to be the protocol that caused less damage to enamel surface, therefore this protocol is suggested for debonding brackets.INTRODUÇÃO: a preservação da estrutura de esmalte após a remoção dos acessórios ortodônticos é obrigação do clínico. Portanto, procura-se um protocolo de descolagem com bases científicas. OBJETIVO: objetivou-se avaliar por microscopia eletrônica de varredura (MEV) a influência de quatro protocolos de remoção de braquetes e polimento da superfície do esmalte e propor um protocolo que minimize os danosà superfície do esmalte. MÉTODOS: doze incisivos permanentes bovinos foram divididos em quatro grupos de acordo com os instrumentos utilizados para a descolagem dos braquetes e remoção do remanescente adesivo. Os braquetes foram descolados com o alicate de descolagem reto (Ormco Corp.) nos grupos 1 e 2, e com o instrumento de descolagem Lift-Off (3M Unitek) nos grupos 3 e 4. Os remanescentes adesivos dos grupos 1 e 3 foram removidos com o alicate removedor de resina longo (Ormco Corp.) e dos grupos 2 e 4 com broca de carboneto de tungstênio (Beavers Dental) em alta-rotação. As superfícies, após cada etapa da descolagem e polimento, foram avaliadas em réplicas de resina epóxica e foram obtidas eletromicrografias com aumento de 50 e 200X. RESULTADOS: os quatro protocolos de remoção de acessórios ortodônticos e polimento ocasionaram irregularidades no esmalte. Conclusão: a remoção do braquete com o alicate de descolagem reto, seguido da remoção do remanescente adesivo com broca de carboneto de tungstênio e polimento final com pasta de pedra-pomes foi o procedimento que ocasionou menores danos ao esmalte, sendo o protocolo sugerido para a remoção dos acessórios ortodônticos

Multidisciplinary treatment ofadult patients with Class III malocclusion

This article describes the multidisciplinary treatment of an adult patient presenting with Angle Class III malocclusion, alteration of the mandibular position, vertical alveolar bone loss and absence of teeth in the lower posterior region. With advancing age the existence of occlusal interference due to loss of teeth or tooth structure is very common, resulting in periodontal problems due to occlusal trauma. The options for treatment of Class III malocclusion in adolescent and adult patients include compensatory orthodontic treatment in mild to moderate cases and orthognathic surgery for moderate to severe cases. The combination of various dental specialties enabled improvement in the social circumstances of the patient. This can be observed objectively by the final dental relationship and by the skeletal and tegumentary cephalometric comparison between the situation at the beginning and at the end of the treatment. The compensatory treatment performed permitted the successful correction of a Class III malocclusion in the clinical case presented.Este trabalho descreve o tratamento multidisciplinar de um paciente adulto com má oclusão de Classe III de Angle, alteração postural da mandíbula, perda óssea alveolar vertical e ausência dentária na região póstero-inferior. Com o avanço da idade é muito comum a existência de interferências oclusais devido à perda de dentes ou de estrutura dentária, resultando em problemas periodontais devidos ao trauma oclusal. As opções de tratamento da má oclusão de Classe III em adolescentes e pacientes adultos incluem tratamento ortodôntico compensatórios em casos suaves a moderados e cirurgia ortognática para casos moderados a severos. O resultado clínico da interação de diferentes especialidades odontológicas permitiu uma melhora do aspecto social da paciente, objetivamente pela relação dentária final e pela comparação cefalométrica esquelética e tegumentar entre o início e final de tratamento. O tratamento compensatório realizado possibilitou o sucesso na correção de uma má oclusão de Classe III do caso clínico apresentado

A utilização do diagrama individual anatômico objetivo (DIAO) no contorneameento de arcos ortodônticos

A morfologia das arcadas dentárias sobre as bases ósseas é conseguida utilizando-se fios ortodônticos, os quais detêm o potencial de correção das irregularidades dentárias. O presente artigo discute conceitos acerca da morfologia das arcadas dentárias, bem como demonstra a utilização do Diagrama Individual Anatômico Objetivo (DIAO). A premissa básica para o contorneamento dos arcos de nivelamento reside na individualização da forma da arcada dentária, que deve considerar as bases ósseas e o relacionamento entre elas, bem como os objetivos terapêuticos. O contorneamento dos arcos de nivelamento baseado no diagrama individualizado torna prática a rotina ortodôntica por favorecer a constância de forma e garantir a simetria da arcada dentária

Mandibular cortical bone evaluation on cone beam computed tomography images of patients with bisphosphonate related osteonecrosis of the jaws

Objectives The objective of this study was to develop a technique for detecting cortical bone dimensional changes in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ). Study Design Subjects with BRONJ who had cone-beam computed tomography imaging were selected, with age- and gender-matched controls. Mandibular cortical bone measurements to detect bisphosphonate-related cortical bone changes were made inferior to mental foramen, in 3 different ways: within a fixed sized rectangle, in a rectangle varying with the cortical height, and a ratio between area and height. Results Twelve BRONJ cases and 66 controls were evaluated. The cortical bone measurements were significantly higher in cases than controls for all 3 techniques. The bone measurements were strongly associated with BRONJ case status (odds ratio 3.36-7.84). The inter-rater reliability coefficients were high for all techniques (0.71-0.90). Conclusions Mandibular cortical bone measurement is a potentially useful tool in the detection of bone dimensional changes caused by bisphosphonates. Long-term administration of bisphosphonates (BPs) affects bone quality and metabolism following accumulation in bone.1 Since the first cases of bisphosphonate-related osteonecrosis of the jaw (BRONJ) were published in 2003,2 there has been a search for factors that can predict the onset of the condition. Oral and intravenous BPs reduce bone resorption, increase mineral content of bone, and alter bony architecture.3, 4, 5 and 6 Previous studies have demonstrated these changes both radiographically and following histologic analysis.1, 3, 7, 8, 9 and 10 The BP-related jaw changes may present radiological features, such as thickening of lamina dura and cortical borders, diffuse sclerosis, and narrowing of the mandibular canal3 and 11; however, oral radiographs of patients taking BPs do not consistently show radiographic changes to the jaws.11 and 12 The challenge is to find imaging tools that could improve the detection of changes in the bone associated with BP use. Various skeletal radiographic features associated with BRONJ in conventional periapical and panoramic radiographs, computed tomography, magnetic resonance imaging, and nuclear bone scanning have been described.3, 8, 9, 10 and 11 There has also been a search for BP-related quantitative methods for the evaluation of radiographic images, to avoid observer subjectivity in interpretation. Factors thought to be important include trabecular and cortical structure, and bone mineralization.4 Consequently, measurable bone data have been reported in subjects taking BPs through many techniques, including bone density, architecture, and cortical bone thickness.1, 4, 7 and 13 Trabecular microarchitecture of postmenopausal women has been evaluated with noninvasive techniques, such as high-resolution magnetic resonance images showing less deterioration of the bone 1 year after initiation of oral BP therapy.4 A decrease in bone turnover and a trend for an increase in the bone wall thickness has been detected by histomorphometry in subjects taking BPs.1 Alterations in the cortical structure of the second metacarpal have been detected in digital x-ray radiogrammetry of postmenopausal women treated with BPs.7 Mandibular cortical width may be measured on dental panoramic radiographs, and it has been suggested as a screening tool for referring patients for bone densitometry for osteoporosis investigation.14 and 15 Inhibition of the intracortical bone remodeling in the mandible of mice taking BPs has been reported.16 Thus, imaging evaluation of the mandibular cortical bone could be a biologically plausible way to detect BP bone alterations. Computed tomography can assess both cortical and trabecular bone characteristics. Cone-beam computed tomography (CBCT) can provide 3-dimensional information, while using lower doses and costing less than conventional CT. The CBCT images have been studied as a tool for the measurement of trabecular bone in patients with BRONJ.13 Therefore, cortical bone measurements on CBCT of the jaws might also help to understand bone changes in patients with BRONJ. There is no standard in quantifying dimensional changes of mandibular cortical bone. We explored several different approaches to take into consideration possible changes in length, area, and volume. These led to the 3 techniques developed in this study. This article reports a matched case-control study in which mandibular cortical bone was measured on CBCT images of subjects with BRONJ and controls. The aim of the study was to explore the usefulness of 3 techniques for detecting mandibular cortical bone dimensional changes caused by BP