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Home , Maxilla, Vomer

International Journal of Dental and Health Sciences Original Article Volume 04,Issue 05

THE ANALYSIS IN RELATION TO CLASS III USING THREE DIMENSSIONAL IMAGES ANALYSIS Ammar Mohi 1, Kadir Beycan2, Şebnem Erçalik Yalçinkaya3 1Postgraduate PhD researcher, Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Marmara University, Istanbul, Turkey. 2Assistant professor , Department of Orthodontics, Faculty of Dentistry, Marmara University, Istanbul, Turkey. 3Professor, Chairman and Head of Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Marmara University, Istanbul, Turkey.

ABSTRACT: Objective: To evaluate the vomer bone dimenssional outline changes in relation to the midface hypoplasia of a Class III malocclusion by comparing with normal controls using a three dimenssional CBCT images analysis of Mimics 19.0 software. Material and Method: In total of 96 patients images were both Class III malocclusion as study cases and normal as controls with age between 15 to 30 years old. All patients were classified into three group based on ANB angular value of Steiner’s analysis. The study group were : normal, mild and sever malocclusion type groups. Linear and angular planes were determined by using 13 skeletal points and analysed by using Mimics 19.0 software. All study groups parameters statistically analysed for significant differences and correlation. Results: A high significant differences between the vomer bone anterior variables (P<0.01) followed by vomer posterior variables (P<0.05) in relation to cranial and midfacial measurements with positive correlation. The pattern of vomer bone was shown highly anterior impaction and backward inclination in sever type malocclusion group and male higher than female. No statistically significance at different ages. Conclusion: Within this study limitation, the eventual role of the vomer bone affect dentofacial complex contour that accuratly appear using 3D image analysis of CBCT software. Keywords: Mimics , Steiner’s analysis, Vomer bone, Class III maloclusion.

INTRODUCTION:

A skeletal Class III malocclusion is one of septal , the perpendicular plate of the most difficult dentofacial problem to the and the vomer. [5-8] treat with a consequence of maxillary Indeed, last centry studies determined the deficiency, resulting in a concave profile. role of vomer bone in sustaining good [1,2] Maxillary deficiency or midfacial occlusion and a balanced stomatognathic hypoplasia characterized by deficiency of system. [9-11] skeletal height, width, and anterioposterior As a result, remodeling and reconfiguration relationships of nasomaxillary complex, of the midfacial surfaces have an which requires multidirectional correction. adaptation response represented by the [3,4] vomer bone which act as a space Remarkably, the as an maintaionr to compenste the dentofacial important functional matrix consists of pattern discrepancy through malocclusion

*Corresponding Author Address: Dr. Ammar Mohi. E-mail: [email protected] Mohi A.et al, Int J Dent Health Sci 2017; 4(5):1148-1157 development in different manner according This is a retrospective study undertaken at to sex, age and other factors. [12,13] A the Department of Oral and Treatment Approach to the malocclusion Dentomaxillofacial radiology, faculty of under that consideration of craniofacial Dentistry, Marmara University, Istanbul, dynamics has a better prognosis with Turkey. The study comprised CBCT images accuarte result in demand. [14] of one hundred patients’ with age between 15-30 years old for both angle class III The morphometry of malocclusion could be malocclusion and normal dentofacial evaluated by use of two dimenssional (2D) pattern. A comparison was made with the radiographs analysis which has limitation determination of vomer bone dimensional such as structural superimpositions in two- changes. dimensional imaging, particularly in the regions of the of the midfacial complex and Pre-operative CBCT scan data of the loss of accurate view. [15] craniofacial skeleton were reconstructed in three level (cranial, midfacial, vomer) and Currently, CBCT as a three-dimensional (3D) on each scan thirteen osseous landmarks diagnostic element may provide advantages were determined in linear and angular over (2D) conventional radiographs of the measurements using mimics 19.0 version midfacial compartment. CBCT has been analysis tool software package (Materialise, shown to provide a high resolution imaging Leuven, Netherlands). A subset of these that allows the qualification and landmarks can be seen in (Table.1). quantification of facial bone tissues in approximately real dimensions without An outline border of the vomer bone was significant magnification or distortion. [16] examined in all subjects images with the same set of osseous landmarks being However, some of CBCT studies have failed determined on transsagittal view of CBCT. to demonstrate clearly the superior Shape analysis for three group of different diagnostic capability of newly computer- dentofacial pattern (normal, mild and based software like MIMICS like accurate sever) midface hypoplasia type groups was postion and spatial pattern of examined performed using Steiner’s (ANB) angle vomer bone. [17] analysis. For that facts, this study hypothesized that There were several steps performed for the the vomer bone in relation to class III vomer outline determination from malocclusion need to be reviewed in surrounding hard tissue for construction for accuarte three imenssional analysis. Thus different type groups. Firstly, the skeletal this study aimed to evaluate the vomer bone scale threshold used. (Figure.1) Then bone dimenssional changes in relation to the 13 landmarks selected for the cranial, midfacial deficiency of class III malocclusion midfacial and vomer bone planes using 3D CBCT analysis tool of Mimics 19.0 determination. (Figure.2) version software.

MATERIALS AND METHODS: 1149

Mohi A.et al, Int J Dent Health Sci 2017; 4(5):1148-1157 After planes determination, the midfacial reference (Table.2) and angular inclination area cropped using growth growing tool (Table.3) determination were examined. then segmented and the vomer bone The linear measurements of the vomer planes outlined. (Figure.3) The conversion bone diminished transsagittaly (Alp-C), (Ala- of the resulting vomer bone outline to the C), (C-BV) when (ANS-PNS) and 3D analysis for each patient in three study cranial base (N-S) planes diminished groups was performed. (Figure.4) all planes (p<0.01). There was less significant measurements of the shape difference of difference to the vertical posterior vomer the vomer bone described accurately with parameters (Alp-BV), (Ala-BV) in relation to in linear and angular vertical facial variables (N-ANS), (S-PNS) relations. (p<0.05) but still have a positive correlation with severity of malocclusion. (Table.4) Finally, the vomer morphometric significant surprisingly anterior inclination of vomer differences and correlation statistically bone (Ala-C-BV) be more diverge with analyzed, to investigate if this positive correlation of increasing ANB angle measurements could be a contributory toward long profile with class III factor affecting malocclusion development. malocclusion. (Table.5) RESULT: Remarkabley, the vomer bone appeared Data analysis of study groups obtained in backward inclined by (CBV-ANS) value in total of one hundred patients. Four patient relation to occlusal plane of maxilla (ANS- excluded from this study because of image PNS) diminishing and increasing the ANB distortion. In result 96 patients were angle with sever type group. No statistical (45.8%, n = 44) female and 54.2% (n = 52) differences between posterior inclination male. The ages of the cases ranged from 15 and the vomer bone dimensional change in to 30, with an average of 23.23 ± 3.92 all groups. However; there was a years. When three different types considerable increasing between mild and examined according to ANB Steiner’s angle; sever type group angular inclination. Shape 37.5% (n = 36) were normal (A type) group, analysis of the vomer bone in class III 18.8% (n = 18) were mild (B type) and malocclusion using 3D CT scans was 43.8% were sever (B type) group (n = 42). appeared the vomer bone backward- No significant difference between the mean upward displacement direction. age and study type groups (p> 0.05). There Statistical analysis of the data was was a significant difference between male performed using SPSS program (version and female with three type groups (p 22.0, SPSS, Chicago, IL, USA). The Kruskal <0.01). The incidence of sever malocclusion Wallis test was used in the comparison of pattern type in males than females is the three groups with no normal significantly higher. distribution. Spearman's Correlation When the cranial, midfacial and vomer Analysis was used to evaluate inter-variable measurements of study groups in linear

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Mohi A.et al, Int J Dent Health Sci 2017; 4(5):1148-1157 relationships. Significance was assessed at The reason was to obtain a clear p<0.05 and p<0.01. landmarking and excellent reproducibility in positioning them. In this way, the (3D) To determine intra-observer reliability and reconstructed vomer bone was not assess cephalometric method error, extended forward to the ANS point and duplicate 3D tracing and measurements of base of the vomer was not at alar region. 25 randomly selected images were This must be considered in the performed by the same investigator after 1 interpretation of the results. month. Random and standard errors were calculated by correlation, which showed The Dentofacial class III discrepancy has values between 0.80 and 0.99, and paired been reported as a unique anatomical samples t-test between first and second variation of midface complex angular and linear measurements. No pathoetiology. [2,11] Although there are systematic errors were detected. various theories about its distinct, it is still a matter of debate. [3,4] DISSCUSSION: Some authors have mentioned the This study results showed that the vomer potential role of vomer bone in the bone has very interesting interrelations development of malocclusion. There is a with malocclusion development. Last functional complex involving the midfacial decades, the vomer bone remains hidden complex and vomer.[21] This complex has because of difficulties in identifying it using some degree of dynamic interrelation conventional (2D) radiographs. [15,18] through sutures. Transmission of forces The application of the (3D) CBCT, and the from the occlusion, or from any other possibility of reconstruction digital model structure can influence the entire complex. provided the opportunity to analyze the [22] The role of vomer bone in the identified bone with great accuracy and transmission of the masticatory forces was reproducibility [19,20] using a professional also described that indicated transmission software. [5] of the masticatory forces through the vomer to the . [23,24] The analysis of parameters developed by defining landmarks and planes. These were Indeed, several studies had been used in the 2D conventional standard highlighted the morphometric relation of cephalometric then the data compared the vomer bone with the ontogeny of the with other study results. Some of midfacial skeleton. [5,25] parameters redefined in 3D environment in Although the author did not find a reason order to be able to correlate accuratly same to believe the importance of the septal anatomical structures. [18] cartilage in the growth of the maxillary The definition of the reconstructed vomer complex, the results were consistent with bone points slightly differs from that of a the correlation found in this study but with appaerd in previous vomer bone study. [17] different parameters and more accuarte

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Mohi A.et al, Int J Dent Health Sci 2017; 4(5):1148-1157 discription analysis using 3D analysis. Other malocclusion with cranial base dimensional studies have been described the changes and maxillary retrusion but did not importance of the vomer bone in the mentioned the vomer bone. [2,29-31] growth deficiency of the maxilla in the As well as, the posterior vertical vomer clefts patients.[25] planes (Ala-Alp), (Ala-BV) positively In the postnatal development of the nasal proportional with vertical anterior (N-ANS), septum, described some of cartilaginous posterior midface (S-PNS) planes structure could increase the ability of the measurements with a high statically septum to transfer forces from the significant (p<0.05) with positive region to the sphenoid bone. In this study, a correlation. That researches reported these description of the the dimension increase of parallel findings but in short determination the vomer bone was established by to the nasomaxillary effect on the apposition in the anterior surface during development of vertical facial profile with the first 12 years, and in the posterio- the malocclusion. [32] superior margin (ala of the vomer) was However, there was no statistical significant until 17 years in men and 15 years in or correlation between the vomer bone woman.[26] variables and vertical midsagittal N-ANS Last decades, some studies have been planes anteriorly or posteriorly S-PNS (p indicated that trauma to the vomer bone >0.05). may impair anterior–posterior growth of The small region is most the premaxilla and maxilla. Also they important in midface growth and different reported that alteration in the vomero- parameters used for that evidence proof. maxillary suture in the etiology of the One of these parameters was anterior midfacial retrusion of the clefts and vomer-premaxilla C-ANS which has high reported also that the maxillary complex significant and correlation with the was displaced forward-downwards in midfacial deficiency by the vomer bone relation to the vomer bone.[27,28] apex (C) point retarted anteriorly. [33,34] From the results of this study, the vomer All vomer bone posterior angular values bone variables were seem a high significant (AlpAlaBV, BaAlaBV, CBVAlp, CAlaBV were differences (p<0.01) with linear and angular statistically significant (p<0.05) with a measurements in all examination level and negative correlation in relation to cranial in all study groups. Firstly; upper cranial base angle (NSBa), intermaxillary angle base plane (N-S) and lower maxilla occlusal (ANB) and facial convexity profile (NAB) plane (ANS-PNS) length diminished measurements. That result revealed the transsagittaly with the dimensional evidence of compensation by posterior the decreasing of the vomer bone planes (Alp- vomer bone angulation. So increasing C), (Ala-C), (BV-C) decreased respectively posterior vomer inclination led the vomer with positive correlation. Some researcher bone pushed forward to preserve anterior reported the relation of class III 1152

Mohi A.et al, Int J Dent Health Sci 2017; 4(5):1148-1157 contour of midface through posterior Nowadays, using of the CBCT and its vomer parameters. Also a high significant applications in craniofacial diagnosis positive correlation was found between the provide a new alternatives to evaluate the anterior vomer bone impaction angle morphology of the malformed skeleton in a AlaCBV and cranial angle NSBa, three-dimensional way with great accuracy. intermaxillary angle ANB and facial [16] More longitudinal evaluation studies in convexity NAB measurements (p<0.05). growing patients childhood period and later [11,35] That result give a rational evidence of life with a large sample should be the vomer bone anteriorly displacement by conducted in order to complement the posterior alar-sphenoidal region to understanding of its role in the craniofacial balanced the increasing in ANB angulation. architecture. Thus a new finding interesting result of this CONCLUSION: study that a strong relation of C-ANSPNS and Ala-CBV inclinations with ANB angle There is a high significant differences and during malocclusion development. [10,13] correlation of vomer bone dimensional changes with midface complex of angle Thus, a high significant differences of vomer class III malocclusion. An orthodontist must bone emphasize a strong correlation also consider other parameters like soft anteriorly transagittal planes and tissue parameters like nasolabial posteriorly vertical planes with maxillary musculature anteriorly and Pterygoid retrusion especially in type C severe group musculature complex posteriorly while when it was compared with other study undertaking decision for orthodontic groups. This study findings give an malocclusion patients. emphasis of the hypothesis of the force transferring from occipital to maxilla In order to evaluate a more reliable through vomero-sphenoidal and the relationship of the vomer bone with reverse forces through the vomer bone dentofacial discrepancy pattern, further from masticatory dentofacial forces. [36,37] studies are still needed to be conducted.

REFERENCES:

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FIGURES:

Figure.1 Bone Scale Threshold

Figure.2 Dimensional measurements of different planes

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Mohi A.et al, Int J Dent Health Sci 2017; 4(5):1148-1157

Figure. 3 Vomer Bone Outline Determination

Figure. 4 Vomer Bone 3D model analysis

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