Biomed Tech 2012; 57:65 69 2012 by Walter de Gruyter Berlin Boston. DOI 10.1515/bmt-2011-0036 Orofacial characteristics of adolescents with diagnosed spinal disorders András Végh1, *, Gábor Fábian 2, Rodica Jianu 3 and Emil Segatto4 1 Department of Orofacial Orthopedics and Orthodontics, Heim P á l Children s Hospital Budapest, 1078 Budapest, Hungary 2 Department of Pedodontics and Orthodontics, Semmelweis University Budapest, 1078 Budapest, Hungary 3 Department of Orthodontics, UMF Victor Babes, Timisoara, Romania 4 Department of Orthodontics and Pediatric Dentistry, Faculty of Dentistry, University of Szeged, Szeged, Hungary Abstract The objective of the current epidemiological study is to show the correlation of various postural abnormalities and spinal deformities and the clinically identifiable dentofacial anomalies by orthodontic examination. Twenty-three children with Scheuermann s disease [mean age: 14 years 8 months; standard deviation (SD): 1 year 8 months] and 28 with scoliosis (mean age: 14 years 7 months; SD: 2 years 3 months) participated in the study. Standardized orthodontic screening protocols were used to map the occlusal relations in the sagittal, vertical, and horizontal dimensions; the space relations of the maxillary and mandibular frontal segment; the temporomandibular joint (TMJ) status; and the facial asymmetries. Statistically significant differences (p < 0.05) were found between the values of the examined groups of patients for the following measurements: incisal overjet and overbite, upper and lower midline deviation, mandibular frontal spacing, TMJ pathological symptoms and functional characteristics, and frequency of facial asymmetries. A large percentage of patients with pre-pubertal developments of spinal deformities have various dentofacial anomalies. The majority of these anomalies are present in patients with Scheuermann s disease. Early treatment of the malocclusions closely correlated to postural disorders should minimize the progression of the dentofacial anomalies, making necessary performing orthodontic screening of these patients as early as possible. *Corresponding author: Prof. Dr. András Végh, Department of Orofacial Orthopedics and Orthodontics, Heim Pál Children s Hospital Budapest, Rottenbiller u.26, 1078 Budapest, Hungary Phone: +36-1-3316529 E-mail: aveghdr@chello.hu Keywords: dentofacial anomalies; Scheuermann s disease; scoliosis. Introduction The literature exploring the causes of the development of malocclusions heavily deals with their connection with different postural anomalies. Mainly, postural anomalies that could contribute to the development of different dentofacial anomalies and later to the sustenance thereof by chronic influence on head posture are highlighted [3, 16]. Thus, orthopedic disorders that mainly manifest in the pathological curves of the spine become very important [11, 14]. According to literature sources, the frequency of the different occlusion deformations malocclusions is 83 87 % in the orthopedic patient group [5]. The role of head posture tilted forward and backward that evolved as a consequence of the pathological curves of the sagittal plane (kyphosis and lordosis) has been mainly examined in the development of the sagittal and vertical jaw anomalies [1, 7]. According to previous studies, the scoliotic curves in the frontal plane through the head posture tilted sideward play a role in the development of the different dentofacial asymmetries [8, 11]. Alterations in head posture may lead to the development of temporomandibular joint (TMJ) dysfunction and TMJ structural deformity [4]. Because of their similar epidemiologic characteristics incidence, stability of the developed deformations, and appearance time the two spinal diseases considered most appropriate in terms of the examinations are Scheuermann s disease (MSCH) (or kyphosis dorsalis juvenilis) and idiopathic scoliosis (SC) [13]. The incidence of MSCH varies between 0.4 % and 11 %. In MSCH, the pathological kyphotic curvature, which is responsible for the forward-tilted head posture and a hunchback appearance, is primarily pronounced and stabilized in the dorsal spinal region (Figure 1 ). Its development begins during pre-puberty and is not characterized by generic deflection [2, 6, 12]. The frequency of idiopathic SC is between 11.9 % and 16.2 %. The main curvature may be localized to any part of the vertebral column, the most common being the right convex dorsalis SC, which in the non-compensated forms induces a left-tilted head posture (Figure 2 ). Its development starts during pre-puberty, and is seven to 10 times more frequent in girls than in boys [17, 18]. The conservative treatment in the early stage of both spinal diseases consists of posture strengthening and improving the muscle tone by physical therapy. In the late, severe stages, wearing a corset is necessary, owing to the rate of the deformed vertebra s malformation stage in MSCH and the Cobb value of > 20 in patients with SC [15, 18].
66 A. V é gh et al.: Dentofacial anomalies and scoliosis advance, and their parents provided written consent for participation in the study. The examinations complied with the requirements of the local Ethics Committee. Materials and methods Figure 1 Lateral X-ray of a Scheuermann s kyphotic spine. We performed orthodontic examination of children with Scheuermann s kyphosis and those with idiopathic SC, to collect data for further related studies. By using the outcomes, we aimed to obtain a more accurate image of the craniofacial characteristics, functional habits, and occlusal patterns of patient groups having spinal deformities in the sagittal and frontal planes. Patients participating in the epidemiological survey received detailed information on the examinations in For the epidemiologic study, 65 patients with recently diagnosed MSCH and idiopathic SC were referred by the Orthopedic Department. Fourteen of these patients had a history of orthodontic treatment; hence, they were excluded from the study. From the remaining 51 children, 23 consist the MSCH the group and 28 the SC group. Through the differences of the generic distribution characterizing the two orthopedic groups, data of both girls and boys were evaluated together. Eight children in the MSCH group and nine in the SC group were wearing a corset because of the severity of their orthopedic malformation. For the examination of the selected children, a standardized orthodontic protocol was used, including taking a dental impression and the usual dental and facial photos immediately before the clinical examination. The results of the evaluations were tabulated on the World Health Organizationrecommended broadsheet for epidemiological studies. The examination of orthodontic particularities was focused around four groups of questions. The measurement of the occlusal characteristics in the sagittal plane was based on the determination of the molar relation (Angle classification) and on the overjet of the incisors. The presence of transversal abnormalities was measured by the registration of the crossbite in the molar region, of the upper and lower midline in relation to the facial midline, and of the midline shift. To study the vertical abnormalities, the lateral open bite was registered and the overbite of the incisors was measured. For the examination of jaw space relations, crowding and spacing in the incisor region were recorded. In the profound examination of the TMJ, the abnormal symptoms (clicking of the joints, pain, limited mouth opening), the mentum deviation during mouth opening, and the rate of the lateral movement were marked and measured. Finally, visible facial asymmetries were visually assessed using well-defined, predetermined criteria. Evaluation of the sheets and statistical analysis of values were performed with the aid of Microsoft Excel 2002 (Microsoft Corporation, USA), and the significance level in all tests was determined to be p < 0.05. Figure 2 Frontal X-ray of a scoliotic spine. Results The sagittal abnormalities in the posterior region were examined by analyzing the molar relations (Angle classification). Unilateral and bilateral neutral occlusions, distal occlusions, and mesial occlusions were recorded separately. In both patient groups, the incidence rate was about equal, and no significant differences were detected. The only noticeable phenomenon was that the frequency of unilateral distal occlusions (30.4 % for the MSCH group, 22.4 % for the SC group) was substantially higher in both patient groups than the frequency of
A. V é gh et al.: Dentofacial anomalies and scoliosis 67 Figure 3 Figure 4 Means ± SD of the overjet values in the studied groups. Means ± SD of the overbite values in the studied groups. bilateral distal occlusions (21.7 % and 10.7 %, respectively). The presence of sagittal deviations in the frontal region was recorded by measuring the overjet of the incisors. Besides the normal overjet, cases presenting an extreme overjet ( 6 mm) and a frontal crossbite were recorded separately. Although in the examined patient groups, the frontal crossbite was not registered, there was a significant difference in the incidences and in the mean values of the two other indexes. The incidence of normal overjet in the SC group was substantially higher and there was a large difference between the means (Figure 3 ). By examining the values of the extreme overjet, the significantly higher incidence rate and average occurrence was found characteristic to the MSCH group. Examining the data of vertical abnormalities, there were no detectable posterior open bite cases. To determine the vertical anomalies of the frontal region, the registration of the normal overbite, the deep bite 5 mm, and the open bite 0 mm was used. In the MSCH group, normal overbite values were substantially more infrequent and the mean values are also differentiated from those of the SC group (Figure 4 ). In the MSCH group, the frequency of the deep bite cases was higher, while the majority of frontal open bite cases were registered among the SC patients. The study of occlusal anomalies was finalized with the analysis of the transversal relations (Table 1 ). One child in the MSCH group and three children in the SC group were registered with a unilateral crossbite, and there were 1 1 bilateral crossbites in both groups. Evaluation of the records on the frontal region gave a better-estimated picture. Just like in the upper midline, the lower midline s deviation from the facial midline was more frequent in the MSCH group than in the SC group. The higher number of midline shifts was characteristic for the MSCH group; however, the SC group was described as having higher deviation means. Evaluation of space anomalies in the jaws involved recording of crowding and spacing in the upper and lower frontal regions. With almost equivalent crowding and upper spacing values, the incidence of spacing in the lower region showed a significant difference, being higher in the SC group. During the clinical examination of TMJ in almost a quarter of the SC group, a pathological symptom was registered, as opposed to the MSCH group where only 4.3 % had an abnormality. The study of the mandibular lateral movement recorded two significantly different movement ranges in the studied groups (Figure 5 ). Only half of the patients in the SC group were able to make the same range of bilateral movement, while in the MSCH group the frequency of these patients is 60.9 %. The visual record of facial asymmetries showed asymmetry in 78.3 % of the MSCH group, which is significantly higher than that recorded in the SC group (57.1 % ) (Table 2 ). In the two patient groups, comparing the parameters of the subgroups on the basis of the severity of spinal deformities, significant differences were seen only in the midline shifts and in facial asymmetries. Both parameters were directly proportional to the severity of the orthopedic deformation (Figures 6 and 7 ). Table 1 Occlusion parameters of the studied groups. Direction and site of malocclusion Parameters Scheuermann s disease group Scoliosis group p-value Sagittal incisal relation Normal overjet frequency (%) 78.26 96.42 0.00068 Normal overjet mean (mm) 1.869 2.357 0.00708E-03 Vertical incisal relation Normal overbite frequency (%) 60.86 75.00 0.288 Normal overbite mean (mm)3.6082.642 0.00293E-03 Transversal incisal relation Upper midline deviancy from the facial midline 60.86 42.85 0.208 frequency (%) Lower midline deviancy from the facial midline 60.86 32.14 0.041 frequency (%) Midline shift mean (mm)1.0871.214 0.0003
68 A. V é gh et al.: Dentofacial anomalies and scoliosis Figure 5 Lateral movement ranges measured in the studied groups. Discussion The relation between several postural disorders and spinal illnesses causing these disorders and the dental complex were focused on in numerous studies. Among the examined spinal disorders, the incidence of idiopathic SC characterized with a pathologic curvature in the frontal plane is relatively high. However, MSCH with pathological curvature in the sagittal plane is uncommon [7]. In the studies reviewed, pathological postures correlated with dominant kyphotic curvature were frequently encountered; however, Scheuermann s kyphosis is not only evident with the increased curvature values but also with degenerative vertebral changes of the affected spinal section, which causes the posture abnormality to become permanent [2, 9]. The statistically high incidence values, the progression of the disease over time, and the presence of the pathological curvature normal to the scoliotic curvature maintained the participation of the children with MSCH in this epidemiological study. In the majority of studies found in the literature, to register dentofacial anomalies, data were obtained by evaluating X-ray records [3, 5, 7]. Those rare articles that described using orthodontic examination results for early detection of spinal disorders, or those that emphasized the necessity of early orthodontic checkups for children with diagnosed spinal disorders, highlight the application of non-invasive methods of screening the affected population [8, 11]. This study is also based on those methods because of the practical reasons cited. Based on previous results in the SC group showing the dominance of dentofacial asymmetry, in the MSCH group the sagittal and vertical alterations caused by the forward-tilted head posture and an increase in the number of TMJ abnormalities were expected [3, 7, 14]. After the evaluation, in most Figure 6 Presence of midline shift in groups with different severities. Figure 7 Means ± SD of the midline shift values characteristic for groups with different severities. cases our values were similar to those of previous studies; however, some exceptions were found. Asymmetric deviations of the posterior region in the sagittal dimension were more frequent in the MSCH group, and the frontal crossbites characterizing mostly patients with SC were not registered in the examined patient group [8]. Examination of incisor relations proved the previously found correlation between the alterations in the sagittal plane and the pathological kyphotic curvature. Just like the extreme overjet, the deep bite was significantly more frequent in patients affected by MSCH. The number of lateral crossbites was minimal in both groups; however, the transversal deviations of the frontal Table 2 Dentofacial parameters of the studied groups. Examined region Parameters Scheuermann s disease group Scoliosis group p-value Temporomandibular joint Presence of symptoms and signs, frequency (%) 4.34 21.42 0.0122 Lateral movement to the right, mean (mm) 5.478 5.821 0.00341E-21 Lateral movement to the left, mean (mm) 5.826 5.714 0.00538E-20 Facial asymmetry Presence of facial asymmetry, frequency (%) 78.26 57.14 0.00068
A. V é gh et al.: Dentofacial anomalies and scoliosis 69 region could have been evaluated. The incidence indicators of the dentofacial asymmetry characterizing patients with SC were exceeded by the values of the MSCH group, for the deviation of the upper and lower midline as well as for the midline shift. The mean dimension of the midline shift was significantly higher in the scoliotic group. In the literature, opinions are divided of the correlation between poor head posture and alterations of the TMJ [5]. Some favor the theory that in case of the forward-tilted head position, the displaced center of gravity can be a risk factor in the development of TMJ dysfunction; others say that a laterally tilted head posture favors the mandible deviation loading the articulation asymmetrically [4, 16]. The latter hypothesis seems to be proved by the numerous pathological symptoms of TMJ registered among scoliotic patients, together with the many asymmetrical indexes found for the lateral movements. The difficulty of this question group is shown by the concordant or the contrary results of this study compared with the ones previously found in the literature studying the etiological roles of spinal deformities with unclear origins in the development of craniofacial deformities [10]. Conclusions The data of this epidemiological study prove and partially complete the results of numerous studies in the literature reporting a high number of dentofacial anomalies in children with various spinal diseases. Patients with MSCH were less often screened for orthodontic problems in the past. The higher number of anomalies found among patients affected by this type of spinal deformity shows the necessity of closely monitoring for orthodontic problems, owing to the correlations of the two conditions. References [1] Ben-Bassat Y, Yitschaky M, Kaplan L, Brin I. Occlusal patterns in patients with idiopathic scoliosis. Am J Orthod Dentofacial Orthop 2006; 130: 629 633. [2] Herrera-Soto JA, Parikh SN, Al-Sayyad MJ, Crawford AH. Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann s kyphosis. Spine (Phila Pa 1976) 2005; 30: 2176 2181. [3] Huggare J. Postural disorders and dentofacial morphology. Acta Odontol Scand 1998; 56: 383 386. [4] Kondo E, Nakahara R, Ono M, et al. Cervical spine problems in patients with temporomandibular disorder symptoms: an investigation of the orthodontic treatment effects for growing and non-growing patients. World J Orthod 2002; 3: 295 312. [5] Korbmacher H, Eggers-Stroeder G, Koch L, Kahl-Nieke B. Correlations between dentition anomalies and diseases of the of the postural and movement apparatus a literature review. J Orofac Orthop 2004; 65: 190 203. [6] Lemire JJ, Mierau DR, Crawford CM, Dzus AK. Scheuermann s juvenile kyphosis. J Manipulative Physiol Ther 1996; 19: 195 201. [7] Lippold C, Segatto E, Vegh A, Drerup B, Moiseenko T, Danesh G. Sagittal back contour and craniofacial morphology in preadolescents. Eur Spine J 2010; 19: 427 434. [8] Lippold C, van den Bos L, Hohoff A, Danesh G, Ehmer U. Interdisciplinary study of orthopedic and orthodontic findings in pre-school infants. J Orofac Orthop 2003; 64: 330 340. [9] Lowe TG. Scheuermann s disease. Orthop Clin North Am 1999; 30: 475 487, ix. [10] Mew JR. The postural basis of malocclusion: a philosophical overview. Am J Orthod Dentofacial Orthop 2004; 126: 729 738. [11] Perinetti G, Contardo L, Biasati AS, Perdoni L, Castaldo A. Dental malocclusion and body posture in young subjects: a multiple regression study. Clinics (Sao Paulo) 2010; 65: 689 695. [12] Pizzutillo PD. Non-surgical treatment of kyphosis. Instr Course Lect 2004; 53: 485 491. [13] Rocha E, Pedreira AC. Spinal deformities in children and adolescents: idiopathic scoliosis. J Pediatr 2001; 77: 225 233. [14] Saccucci M, Tettamanti L, Mummolo S, et al. Scoliosis and dental occlusion: a review of the literature. Scoliosis 2011; 6: 15. [15] Sastre S, Lapuente JP, Barrios C. Benefits of F.E.D. treatment in Scheuermann s disease. Stud Health Technol Inform 2002; 88: 270 278. [16] Solow B, Sandham A. Cranio-cervical posture: a factor in the development and function of the dentofacial structures. Eur J Orthod 2002; 24: 447 456. [17] Weiss HR. Rehabilitation of adolescent patients with scoliosis what do we know? A review of the literature. Pediatr Rehabil 2003; 6: 183 194. [18] Wise CA, Barnes R, Gillum J, Herring JA, Bowcock AM, Lovett M. Localization of susceptibility to familial idiopathic scoliosis. Spine (Phila Pa 1976) 2000; 25: 2372 2380. Received August 8, 2011; accepted December 2, 2011; online first January 10, 2012