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Evaluation of a Novel Palatal Suture Maturation Classification As Assessed by CBCT Imaging of a Pre- and Post-Expansion Treatment Cohort

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Evaluation of a Novel Palatal Suture Maturation Classification As Assessed by CBCT Imaging of a Pre- and Post-Expansion Treatment Cohort Evaluation of a novel palatal suture maturation classification as assessed by CBCT imaging of a pre- and post-expansion treatment cohort by Darren Matthew Isfeld A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science Medical Sciences – Orthodontics University of Alberta © Darren Matthew Isfeld, 2017 Abstract: Introduction: Evaluated is the novel midpalatal suture maturation classification and methodology proposed by Angelieri et al. (2013). Reliability testing was performed, followed by a retrospective observational longitudinal (cohort) study to evaluate the reliability and usefulness of this novel classification system to predict success of RME treatment. Methods: Reliability testing focused on a total of sixteen patients aged 9.5 -17 years old with early mixed to full permanent dentition, representing all proposed palatal maturation stages, with accessible pre-expansion CBCTs. The retrospective observational longitudinal (cohort) study evaluated 63 pre-adolescent and adolescent patients aged 11-17 years old with full permanent dentition treated with tooth-borne RME appliances who have CBCTs records taken at T1 pre- and T2 post-expansion. CBCT 3D landmarking produced skeletal and dental widths and dental angulations utilized to evaluate the extent of skeletal and/or dental expansion as it relates to the T1 palatal suture classification of each subject. Results: There was almost perfect intra-examiner agreement and slight to poor inter-examiner agreement, differing from previously reported reliability, affected by necessary operator calibration and the degree of post-acquisition image sharpness and clarity. Results of the cohort study were wholly unsupportive of the efficacy of the proposed palatal suture maturation classification. Further evaluation of its scientific basis determined that the classification was ill- founded. Conclusion: Clinicians should not consider this proposed classification as being factual, and halt employing its use to drive clinical decision making which will have real-world patient implications and outcomes. ii Preface: This thesis is an original work by Darren M. Isfeld. The research project, of which this thesis is a part, received research ethics approval from the University of Alberta Research Ethics Board and the Northern Alberta Clinical Trials and Research Centre (NACTRC), Project Name “Reliability and predictive efficacy of a novel methodology for midpalatal suture maturation classification for individual assessment prior to maxillary expansion”, No. Pro00060813, December 5, 2015. Chapter 1 of this thesis has been published as Novel methodologies and technologies to assess mid-palatal suture maturation: A systematic review. Manuel Lagravere; Darren Isfeld; Vladimir Leon-Salazar; Carlos Flores-Mir. Head face med. 2017 June 14:13(1). Doi:10/1186/s13005-017-01442-2. I was responsible for the data collection, analysis and manuscript composition. All other authors were involved with concept formation, manuscript composition and edits. iii Acknowledgements: I would like to thank all committee members for their time, invaluable input, expertise and guidance in this project. Special and limitless thanks to my thesis supervisor, Dr. Manuel Lagravere, for allowing me to take on this project so last minute. I am certainly grateful for his patience with me, support throughout this study and writing of this thesis. Dr. Lagravere’s critical thinking skills, attention to detail, as well as, being able to see the big picture is inspiring and is something I will certainly try to embolden in myself as I move forward from academia into private practice. With Deepest Gratitude, Darren Matthew Isfeld iv Contents: List of Tables vi List of Figures vii Chapter 1: Introduction and Systematic Review of Literature 1 1.1 Statement of Problem 2 1.1.1 Research Questions 3 1.2 Systematic Review of Literature: Novel methodologies and 4 technologies to assess mid-palatal suture maturation 1..2.1 Introduction 4 1.2.2 Material and Methods 6 1.2.3 Results 10 1.2.4 Discussion 24 1.2.5 Conclusion 34 1.2.6 Literature Cited 36 1.2.7 Appendices 40 Chapter 2: Reliability testing of a novel palatal suture 44 maturation classification 2.1 Introduction 45 2.2 Methods and Materials 48 2.3 Statistical Analysis 52 v 2.4 Results 54 2.5 Discussion 59 2.6 Conclusion 67 2.7 Appendices 69 2.8 Literature Cited 75 Chapter 3: Evaluation of a novel palatal suture maturation classification as assessed by CBCT imaging of a pre- and 77 post-expansion treatment cohort 3.1 Introduction 78 3.2 Material and Methods 86 3.3 Statistical Analysis 95 3.4 Results 97 3.5 Discussion 99 3.6 Conclusion, Limitations & Future Recommendations 110 3.7 Appendices 114 3.8 Literature Cited 126 Chapter 4: General Discussion 131 4.1 Discussion 132 4.2 Literature Cited 137 Bibliography 139 vi List of Tables: Table 1.1: Summary of articles that met final inclusion criteria 11 Table 1.2: Results and conclusions of articles meeting final inclusion criteria 21 Table 2.1: intra-examiner, inter-examiner, and rater to ground truth agreement 54 from classification of 16 patients palatal suture maturation Table 2.2: Frequency table of classification of palatal stage maturation by CF 55 in comparison to ground truth. Bolding denotes the percent frequency of CF correctly classifying the appropriate palatal stage to ground truth. Table 2.3: Frequency table of classification of palatal stage maturation by 56 ML in comparison to ground truth. Bolding denotes the percent frequency of ML correctly classifying the appropriate palatal stage to ground truth. Table 3.1: Maxillary landmarks defined and shown on cross sectional 89 images identified in each subject’s pre- and post-expansion CBCT volumes. Table 3.2: Dental and skeletal linear & angular measurements generated. 90 Table 3.3: Dependent variables – difference in skeletal and dental 94 distances and dental angles from T2-T1. Table 3.4: percent change in dependent variables from pre- to post-expansion (T2-T1). 98 Table 3.5: Summary of histological studies cited as source of findings used to define 105 the proposed palatal suture maturational stages (A-E). vii List of Figures: Figure 1.1: Flow diagram of the literature search. 9 Figure 2.1: Diagrammatic representation of the developed novel 46 palatal suture maturation classification identifying key radiological morphological characteristics specific to each maturity level. Figure 2.2: (a) Representation on proper standardization of head position for 51 image analysis and. (b) axial cross section of the mid-palatal suture generated from this protocol. Figure 2.3: Bland Altman plot evaluating Intra-examiner reliability 57 comparing DAI reading Figure 2.4: Bland Altman plot evaluating Inter-examiner reliability 57 comparing classifications by ML to CF. Figure 2.5: Bland Altman plot evaluating reliability comparing 58 classifications by CF to ground truth (DAI classification session 1). Figure 2.6: Bland Altman plot evaluating reliability comparing 58 classifications by ML to ground truth (DAI classification session 1). viii Figure 3.1: Diagrammatic representation of the developed novel palatal 85 suture maturation classification identifying key radiological morphological characteristics specific to each maturity level Figure 3.2: Orientation of the Cartesian plane coordinate system in 87 3 planes; X (red), Y (green) and Z (blue). Figure 3.3: Spherical markers representing the 3D landmarks of interest 88 visualized in the x, y and z planes within the Avizo software version 7.0 Figure 3.4: Unbalanced distribution of palatal stages across the 92 sample (n=63) as classified according to Angelieri et al[1]. Figure 3.5: Improved balanced distribution of palatal stages across 92 the sample (n=63) after implementation of modified Angelieri et al. classification. ix Chapter 1: Introduction and systematic review of literature 1 1.1 Statement of Problem There is significant variation in the timing of skeletal maturation amongst individuals[2, 3] as the palatal suture fusion is poorly correlated with patient age and sex[1]. Failure to properly identify key clinical signs and provide individual assessment to identify a patient’s ideal expansion treatment option can lead to iatrogenic side effects and co- morbidities[1, 2]. Conversely prematurely committing a patient to surgically assisted expansion ascribes a patient to a potential significant burden of treatment including increased cost, pain and healing time. To minimize sequalae of failed rapid maxillary expansion (RME) and/or avoid the co-morbidities of surgically assisted RME, a reliable method to classify midpalatal suture maturation with predictive ability to drive clinical decision making, towards non-surgical or surgical RME, in adolescent and young adult patients is needed. 2 1.1.1 Research Questions Three research questions were identified: Primary research question – What is the reliability of the Angelieri et al midpalatal suture maturation classification system? Secondary research question – How useful is this novel classification system to predict success of RME treatment? Tertiary research question - What alteration(s) or modification(s) to the Angelieri et al. methodology can be suggested to improve reliability and/or predictive ability of this classification system? 3 1.2 Systematic Review of Literature: Novel methodologies and technologies to assess mid-palatal suture maturation Novel methodologies and technologies to assess mid-palatal suture maturation: A systematic review. Manuel
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