A apneia obstrutiva do sono é uma síndrome que produz múltiplas comorbidades, aumentando significativamente a taxa de mortalidade dos seus portadores. A atresia maxilar vem sendo descrita como um dos fatores etiológicos da SAOS, entretanto não existem estudos que demonstrem a eficácia no tratamento em adultos com consequente redução dos eventos obstrutivos durante o sono. Este trabalho tem como objetivo principal a verificação da expansão rápida da maxila cirurgicamente assistida (ERMCA), nos eventos obstrutivos do sono e demais parâmetros polissonográficos, na sonolência diurna e no comportamento morfométrico da via aérea. A amostra foi realizada em indivíduos adultos com apneia obstrutiva do sono (SAOS), atresia maxilar e mordida cruzada. O método adotado foi um ensaio clínico prospectivo com 16 participantes (7 mulheres / 9 homens) com idade de 40,23 ± 10,23, todos portadores de SAOS comprovada por polissonografia (PSG) de noite toda (IDR superior a 5), atresia maxilar e mordida cruzada posterior. Previamente todos participantes foram submetidos a uma tomografia computadorizada (TC) da via aérea superior e foi aplicado o teste da Escala de Sonolência de Epworth (ESE). Todos os pacientes foram então submetidos à ERMCA, e posteriormente, todos os exames foram refeitos para comparação. Foi constatada uma redução no IDR de 35,46 ± 38,54 para 16,07 ± 19,73, uma redução média de 54,68% (p=0,0013) e no IAH em 56,24% (33,23 ± 39,54 para 14,54 ± 19,48: p=0,001), uma redução dos índices de microdespertares e dessaturação, além da melhora de diversos parâmetros polissonográficos. O ESE apresentou uma melhora de 12,50 ± 5,32 para 7,25 ± 3,53 (p<0,001). A via aérea total ampliou em média 23,99% (p=0,016), mas de uma maneira mais expressiva na sua metade inferior (28,63% p=0,008). Em relação aos resultados obtidos por meio da ERMCA observou-se uma melhora da SAOS, redução dos índices relacionados aos distúrbios respiratórios durante o sono, de microdespertar e de dessaturação, ampliação da via aérea, principalmente na metade inferior, além de melhorar a sonolência diurna, devolvendo- a para a normalidade. / Obstructive sleep apnea syndrome (OSAS) is a condition that produces multiple comorbidities, significantly increasing the mortality rate of affected individuals. Maxillary atresia is being described as one of the etiological factors of OSAS, although there are no studies demonstrating the efficacy of treatment in adults with a consequent reduction of obstructive events during sleep. The main objective of the present study was to determine the effects of surgically assisted rapid maxillary expansion (SARME) on obstructive sleep events and all other polysomnography (PSG) parameters, on daytime sleepiness and on the morphometric behavior of the airways. The study was conducted on adult individuals with OSAS, maxillary atresia and crossbite. The method involved a prospective clinical assay with 16 participants (7 women/9 men) aged 40.23 ± 10.23 years, with OSAS confirmed by all-night PSG (respiratory disorder index (RDI) higher than 5), maxillary atresia and posterior crossbite. All participants were first submitted to computed tomography of the upper airways and to the Epworth Sleepines Scale (ESS) test. All patients were then submitted to SARME and all exams were later repeated for comparison. RDI was reduced from 35.46 ± 38.54 to 16.07 ± 19.73, (a mean reduction of 54.68%, p=0.0013), the apnea-hypopnea index (AHI) was reduced from 33.23 ± 39.54 to14.54 ± 19.48 (a mean reduction of 56.24%, p=0.001), and micro-awakenings and desaturation were also reduced. The ESS score improved from 12.50 ± 5.32 to 7.25 ± 3.53 (p<0.001). Mean total airway area was increased by 23.99% (p=0.016), although in a more expressive manner in the lower half (28.63%, p=0.008). The results obtained by SARME revealed an improvement of OSAS, a reduction of the indices related to respiratory disorders during sleep, of micro-awakennings and of desaturation, as well as airway expansion, especially in the lower half, and improvement of daytime sleepiness with a return to normality.

Les anomalies de croissance maxillo-faciale résultent de variations du processus normal de croissance. Après les caries, elles représentent les problèmes bucco-dentaires les plus fréquents chez les jeunes et peuvent entraîner des troubles fonctionnels (mastication, phonation, respiration), esthétiques et parfois psychologiques. Le traitement orthodontique vise à corriger les anomalies de croissance maxillo-faciale. L’objectif de cette thèse est de rechercher des facteurs de risque précoces d’anomalies de croissance maxillo-faciale et d’étudier le rôle des facteurs socio-économiques, culturels et géographiques de l’accès au traitement orthodontique en France. Les enfants de la cohorte EPIPAGE, qui avait inclus toutes les naissances survenues entre 22 et 32 semaines d’aménorrhée dans neuf régions françaises en 1997, ont été examinés à 5 ans. Nous avons étudié les relations entre les caractéristiques néonatales et la déformation du palais à 5 ans chez 1711 enfants. Le sexe masculin, le petit âge gestationnel, le petit poids pour l’âge gestationnel et peut-être l’intubation de longue durée sont identifiés comme des facteurs de risque de déformation du palais à 5 ans chez les grands prématurés ; de plus, les enfants avec des déficiences neuro-motrices semblent particulièrement à risque. La cohorte mère-enfant EDEN, a inclus des femmes enceintes en 2002-2003 et leur enfant à la naissance. Nous avons recherché les facteurs de risque précoces de l’occlusion postérieure inversée et de la béance antérieure chez 422 enfants de 3 ans. En plus d’une tétine encore utilisée à 3 ans et de la respiration buccale qui sont des facteurs connus, un nouveau facteur de risque d’occlusion postérieure inversée en denture temporaire est mis en évidence : la prématurité. Enfin, l’étude chez les 5988 enfants et les adolescents de l’enquête sur la santé et la consommation de soins en France réalisée par l’Insee en 2002-2003, enquête transversale sur échantillon représentatif de la population vivant en France, montre que 23% des 12-15 ans ont un traitement orthodontique. En plus du facteur économique, le moindre recours au traitement orthodontique est aussi lié à l’environnement social et culturel moins favorisé de l’enfant, à l’absence de couverture complémentaire et à l’habitation en zone rurale.En conclusion, pour mieux comprendre les inégalités dans le traitement orthodontique, il faudrait en évaluer les besoins en amont. Nous avons étudié des facteurs liés à la présence d’anomalies de croissance maxillo-faciale à des âges très jeunes afin de pouvoir identifier tôt des enfants à risque de ces anomalies. Il est nécessaire de vérifier leur évolution pour savoir si elles sont de réels marqueurs précoces de besoin en traitement orthodontique. / Malocclusions are due to variations of normal process of growth. Besides caries, they are the most common oral problems encountered by children and teenagers. They may lead to oral dysfunction (in chewing, speaking and breathing), esthetic and sometimes psychological issues. Orthodontic treatment aims at correcting malocclusions.The purpose of this thesis is to investigate early risk factors for malocclusions and to analyze the role of socioeconomic, cultural and geographic factors in access to orthodontic treatment in France. In the EPIPAGE cohort study, which included all live births between 22 and 32 weeks of gestation in 9 French regions in 1997, 1711 children were examined at 5 years. We explored the relations between neonatal characteristics and alteration of palatal morphology at 5 years. Male sex, low gestational age, small for gestational age and maybe intubation of long duration were identified as risk factors for alteration of palatal morphology et 5 years in very preterm children; children with neuromotor deficiencies seem particularly at risk. The mother-child EDEN cohort included pregnant women in 2002-2003 and their child at birth. We investigated early risk factors for posterior crossbite and anterior open bite in 422 3-year-old children. In addition to ongoing pacifier sucking habit at 3 years and mouth breathing, which are well-known risk factors, prematurity appears to be a new risk factor for posterior crossbite in temporary dentition. Finally, the French survey on health and care consumption, carried out in 2002-2003 in a representative sample of 5988 children and teenagers, shows that 23% of the 12-15 years old have an orthodontic treatment. Besides the economic factor, the less orthodontic treatment uptake is related to a less privileged social environment, to the absence of supplementary insurance and to living in a rural area.In conclusion, to understand inequalities in orthodontic treatment better, orthodontic treatment need should be evaluated first. We investigated factors related to malocclusions at very young ages, which could help to early identify children at risk. The assessment of how these early malocclusions would evolve is therefore needed in order to control if those malocclusions are indeed early markers for orthodontic treatment need.

Orientador: Ary dos Santos-Pinto / Resumo: Este estudo clínico retrospectivo pesquisou, em uma amostra de pacientes com maturação óssea avançada, as alterações esqueléticas e dentárias produzidas com a técnica de expansão rápida da maxila assistida por mini-implantes ortodônticos (MARPE) e comparou com as alterações da expansão rápida maxila assistida cirurgicamente (SARPE). Foi pesquisada também a correlação entre o grau de maturação da sutura palatina mediana (SPM), gênero e idade, com os resultados (sucesso ou insucesso) gerados com a técnica MARPE. Por último, em uma amostra maior de 85 pacientes entre 15 e 58 anos de idade, observou-se a prevalência, por gênero e período etário, dos estágios de maturação da sutura palatina mediana. Para o primeiro objetivo, uma amostra de 17 indivíduos tratados com a MARPE foi comparada com outra amostra de 15 pacientes, com faixa etária semelhante, tratados por meio da SARPE. Tomografia Computadorizada de Feixe Cônico antes(T0) e após(T1) a expansão foram avaliadas. Para o segundo objetivo, a mesma amostra da MARPE foi usada para avaliar as alterações esqueléticas observadas na T0 e T1. Imagens do plano axial da SPM foram extraídas da T0 e classificadas em um dos cinco estágios de maturação sutural. Foi avaliada a taxa de sucesso e insucesso quanto aos fatores idade, gênero e maturação sutural. E, para o terceiro objetivo, foram classificadas imagens axiais de SPM de 85 indivíduos entre 15 e 58 anos, para determinar a prevalência da maturação da SPM em relação ao gênero e idade.... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: In a sample of patients with advanced bone maturation, this retrospective clinical study investigated the skeletal and dental changes produced by mini-implants assisted rapid palatal expansion (MARPE) compared with the changes in the surgically assisted rapid palatal expansion (SARPE). The correlation between the maturation stage of the midpalatal suture (MPS), sex and age was also investigated, with the results (success or failure) generated with MARPE. At last, in a larger sample of 85 patients between 15 and 58 years of age, the prevalence of maturation stages of the MPS was observed by sex and age period. For the first objective, a sample of 17 individuals, treated with MARPE, was compared with another sample of 15 patients with similar age group, treated with SARPE. CBCT before (T0) and after (T1) expansion were evaluated. For the second objective, the sample MARPE was used to evaluate the skeletal changes observed in T0 and T1. Images of the axial plane of MPS were extracted from T0 and classified into one of the five stages of suture maturation. The success rate and failure by age, sex and suture maturation were evaluated. And for the third objective, MPS axial images of 85 individuals, aged 15 to 58 years, were classified to determine the prevalence of maturation of MPS in relation to sex and age. The results showed that there is a wide variation in relation to the maturation stage of MPS founded in late adolescents and adults. MARPE showed to be a procedure with good... (Complete abstract click electronic access below) / Doutor

A expansão rápida da maxila assistida cirurgicamente (ERMAC) é o procedimento de eleição para o tratamento da deficiência transversa de maxila em pacientes esqueleticamente maduros. Controvérsias em relação ao procedimento ainda persistem principalmente relacionadas aos métodos de avaliação, técnica cirúrgica utilizada, morbidade, eficácia clínica e estabilidade de resultados. A utilização da tomografia computadorizada para a avaliação da eficiência da ERMAC é uma opção atual e ainda pouco divulgada. Consequentemente, os parâmetros anatômicos para a utilização deste método ainda não foram totalmente estabelecidos. Os objetivos do presente estudo foram avaliar a confiabilidade da metodologia proposta e as alterações esqueléticas maxilares decorrentes da ERMAC com a utilização do método de avaliação por tomografia computadorizada. No período de junho de 2004 a maio de 2005, 15 pacientes, sendo 10 do sexo feminino, foram submetidos a ERMAC. A técnica cirúrgica utilizada constou de osteotomia maxilar do tipo Le Fort I, sem osteotomia da sutura ptérigo-maxilar, associada a osteotomia sagital mediana do palato. O aparelho expansor utilizado foi do tipo Hyrax. Os pacientes foram submetidos a exames de tomografia computadorizada, em tomógrafos de múltiplos detectores, no pré-operatório e após 6 meses, utilizando-se metodologia idealizada para a avaliação específica deste procedimento cirúrgico. Para a determinação do padrão das alterações transversais e ântero-posteriores, medidas lineares e angulares foram realizadas diretamente na estação de trabalho dos aparelhos de tomografia. Através de imagens obtidas nas aquisições tomográficas axiais e em reconstruções coronais, as regiões anterior, média e posterior da maxila foram avaliadas separadamente. A área de secção transversa da maxila foi também calculada. Após a avaliação dos resultados observou-se que a confiabilidade do método foi estatisticamente comprovada. Um significativo aumento da área de secção transversa da maxila foi observado (p<0.05). Entretanto, o padrão de expansão transversa não se mostrou uniforme. O aumento das dimensões transversas nas regiões anterior e média foi estatisticamente comprovado. Não foi observada expansão transversa significativa na região posterior da maxila. Ao se avaliar a relação entre a abertura do parafuso expansor e a efetiva expansão esquelética da maxila, observou-se que esta foi menor que a abertura do parafuso, em termos absolutos. O aumento transverso relativo à expansão do parafuso foi estatisticamente maior nas regiões anterior e média da maxila do que em sua região posterior. Em conclusão, a avaliação por tomografia computadorizada para a análise das alterações esqueléticas da região maxilar, em pacientes submetidos à ERMAC é metodologia confiável e reprodutível. A expansão transversa da maxila decorrente do procedimento de ERMAC utilizado no presente estudo acarretou uma expansão não uniforme da maxila, com predomínio da expansão transversa nas regiões anterior e média. / Surgically assisted rapid palatal expansion is the procedure of choice for treating transverse maxillary deficiency in mature patients. Some controversies regarding surgically assisted rapid palatal expansion remain, mainly concerning technical aspects such as type and location of osteotomy sites, as well as surgical morbidity, clinical efficiency, and stability. The evaluation of transverse expansion is still a theme of discussion. On conventional anteroposterior radiographs, anatomical structures are superimposed, resulting in a high number of image artifacts, as well as hindering the tracing and evaluation. The use of computed tomography as a method of evaluating the efficiency of this procedure has not been widely reported. Consequently, few landmarks for use in evaluating maxillary expansion have been defined. The goals of the present study were to define parameters to assess skeletal changes after surgically assisted palatal expansion, to evaluate the reliability of the proposed method and to use computed tomography to assess those parameters. From June of 2004 to May of 2005, 15 patients underwent surgically assisted rapid palatal expansion (a modified Le Fort I maxillary osteotomy without pterygomaxillary separation, together with a sagital palatal osteotomy) according to a defined protocol, using a Hyrax appliance. To determine the pattern of transversal and anteroposterior expansion, linear and angular measurements were performed on multislice computed tomography, using computed software directly on the workstation. The anterior, intermediate and posterior portions of the maxilla were evaluated separately, using a specific method, in axial acquisition and coronal reconstructed views. The cross-sectional area of the maxilla was calculated to obtain general information about maxillary expansion. The reliability of the method was statistically confirmed. Significant maxillary overall expansion was observed. However, different patterns of expansion were seen in the three regions analyzed. In the anterior and intermediate portions of the maxilla, the increase in maxillary width was significantly greater than that observed in the posterior portion. The opening of the jackscrew was greater than skeletal expansion. Comparing jackscrew opening and transverse expansion, the same pattern of asymmetric expansion was verified. No change was observed in anteroposterior dimensions. The method of computed tomography evaluation is a useful tool for evaluation of surgically assisted rapid palatal expansion changes. The accurate evaluation of the postoperative changes was heavily dependent upon images acquired through computed tomography. An overall maxillary expansion was confirmed. However, transverse expansion of the maxilla achieved through surgically assisted rapid palatal expansion without pterygoid plate separation was less than uniform.

Introduction : L’expansion palatine rapide assistée chirurgicalement (EPRAC) est une option de traitement privilégiée chez les patients ayant atteint la maturité squelettique et présentant une déficience transverse du maxillaire. L’effet bénéfique de l’EPRAC sur la fonction respiratoire est régulièrement mentionné, toutefois, encore peu d’études ont évalué son impact sur les voies aériennes supérieures. L’objectif de cette étude clinique prospective comparative consistait à évaluer les effets tridimensionnels de l’EPRAC sur la cavité nasale, le nasopharynx et l’oropharynx à l’aide de la tomodensitométrie. Méthodologie : L’échantillon était constitué de 14 patients (5 hommes, 9 femmes) dont l’âge moyen était de 23,0 ± 1,9 ans (16 ans 4 mois à 39 ans 7 mois). Tous ont été traités avec un appareil d’expansion de type Hyrax collé et l’expansion moyenne a été de 9,82 mm (7,5 - 12,0 mm). Tous ont eu une période de contention d’une année avant le début de tout autre traitement orthodontique. Une évaluation par tomodensitométrie volumique à faisceau conique a été réalisée aux temps T0 (initial), T1 (6 mois post-expansion) et T2 (1an post-expansion) et le volume des fosses nasales, du nasopharynx et de l’oropharynx ainsi que les dimensions de la zone de constriction maximale de l’oropharynx ont été mesurés sur les volumes tridimensionnels obtenus. Résultats : Les résultats radiologiques ont démontré une augmentation significative du volume des fosses nasales et du nasopharynx ainsi qu’une augmentation de la zone de constriction maximale de l’oropharynx à 6 mois post-expansion. Par la suite, une portion du gain enregistré pour ces trois paramètres était perdue à un an post-EPRAC sans toutefois retourner aux valeurs initiales. Aucun effet significatif sur le volume de l’oropharynx n’a été observé. De plus, aucune corrélation significative entre la quantité d’expansion réalisée et l’ensemble des données radiologiques n’a été observée. L’analyse de la corrélation intra-classe a démontré une excellente fiabilité intra-examinateur. Conclusions : L’EPRAC entraîne un changement significatif du volume de la cavité nasale et du nasopharynx. L’EPRAC ne modifie pas le volume de l’oropharynx, par contre, un effet significatif sur la zone de constriction maximale de l’oropharynx est noté. Les effets observés n’ont pas de corrélation avec le montant d’activation de la vis d’expansion. / Introduction: Surgically assisted rapid palatal expansion (SARPE) is a treatment of choice for patients who have reached skeletal maturity and present a maxillary transverse deficiency. It is often mentioned that SARPE has the benefit to improve respiratory function, however, only a few research projects have investigated the effects of SARPE on the upper airways. The objective of this clinical prospective comparative study was to evaluate the three-dimensional effects of SARPE on the nasal cavity, the nasopharynx and the oropharynx using computed tomography. Materials and Methods: The sample consisted of 14 subjects (5 males, 9 females) whose mean age was 23.0 ± 1.9 years (range: 16 y. 4 mo. to 39 y. 7 mo.). All patients were treated using a bonded Hyrax expander and the mean expansion was 9.82 mm (7.5-12.0 mm). A one-year retention period was undertaken before the beginning of any other orthodontic treatment. A cone-beam computed tomography (CBCT) evaluation was performed at T0 (initial), T1 (6 months post-expansion) and T2 (1 year post-expansion), and then the nasal cavity, nasopharyngeal and oropharyngeal volumes and the oropharyngeal minimal cross-sectional area were measured on the three-dimensional volumes that were obtained. Results: Radiological results have demonstrated a significant increase of the nasal and nasopharyngeal volumes and also an increase of the oropharyngeal minimal cross-sectional area at 6 months post-expansion. At one year post-SARPE, for these three parameters, a part of the gain was lost but did not return to the initial values. No significant effect on oropharyngeal volume was found. No significant correlation between expansion screw activation and radiological parameters were noted. Intra-class correlation analysis showed excellent intra-examiner reliability. Conclusions: SARPE causes significant changes of the nasal cavity and nasopharyngeal volumes. SARPE does not modify the oropharyngeal volume, but induces significant changes of the oropharyngeal minimal cross-sectional area. The observed effects do not have a correlation with the amount of expansion screw activation.

Introduction : Le bruxisme du sommeil est un désordre du mouvement décrit comme un mouvement involontaire de la mastication durant le sommeil. Cette parafonction est observée dans 14-38% de la population pédiatrique. Un lien a été trouvé entre les événements respiratoires et les épisodes de bruxisme. L’expansion palatine rapide (EPR) est un traitement orthopédique effectué chez les enfants en croissance pour régler un manque transverse squelettique du maxillaire supérieur. Quelques études ont observé que l’apnée obstructive du sommeil a été diminuée par un traitement d’expansion palatine rapide. Objectifs : Étant donné que le bruxisme est en lien avec des événements respiratoires et que l’expansion palatine rapide augmente la dimension des cavités nasales, l’objectif de la présente étude est d’évaluer la possible réduction du bruxisme après le traitement d’expansion rapide. Méthodes : Ce projet pilote est une étude clinique randomisée contrôlée de patients consécutifs qui a inclus 27 enfants (8-14 ans, 8 garçons et 19 filles) avec ou sans bruxisme du sommeil. Tous ces patients sont venus à la clinique d’orthodontie de l’Université de Montréal et présentaient un manque transverse du maxillaire supérieur (au moins 5 mm). Dans le cadre de l’étude, les patients devaient passer un enregistrement polysomnographique ambulatoire avant le traitement d’expansion palatine (T0) et après l’activation de l’appareil d’expansion (T1). Résultats : Les résultats démontrent une diminution du bruxisme chez 60% (9 patients) de nos patients bruxeurs. L’interaction entre le traitement et les groupes (Br et Ctl) s’est avérée significative (p=0,05 ANOVA mesures répétées), et démontre une diminution du bruxisme chez les bruxeurs (p=0,04, t-test paire). Les médianes (min, max) du groupe avec bruxisme sont passées de 3,11 (2,06; 7,68) à 2,85 (0,00; 9,51). Les paramètres de sommeil sont restés stables (Stade N1/N2/N3, REM, efficacité du sommeil), ainsi que les paramètres respiratoires et le ronflement. Conclusion : Une réduction du bruxisme a été observée lors de cette étude, mais un échantillonnage plus grand est nécessaire pour conclure. / Introduction: Sleep bruxism (SB) is a movement disorder described as an involuntary mastication movement during sleep. This parafunction is observed in 14-38% of the child population. A link was found between respiratory events and episodes of bruxism. Rapid palatal expansion (RPE) in children is an orthopedic treatment that is effective in correcting maxillary transverse deficiency and in reducing obstructive apnea syndrome (OAS) by increasing airway capacity. Objectives : Since bruxism is related to respiratory events and RPE increases respiratory capacity, the objective of this study is to evaluate the possible reduction of bruxism after RPE therapy. Material and Methods : This prospective randomized controlled clinical pilot study recruited 27 children (8-14 years old, 8 boys, 19 girls) with or without sleep bruxism. These patients were seeking treatment for transverse maxillary deficiency (5 mm or more) at the orthodontics department of the University of Montreal. Patients underwent an ambulatory polysomnography before (T0) and after expansion (T1). Sleep parameters, rhythmic muscular masticatory activity index were evaluated. Results : The results show a reduction of bruxism in 60% of bruxer patients (9 participants). The interaction between the treatment and the groups (Br and ctl) was significant (p=0,05, repeated measures ANOVA). A reduction of bruxism is shown for bruxers (p=0,04, paired t-test). The sleep parameters stayed stable after RPE (Stage N1/N2/N3, REM, sleep efficiency) as well as the breathing parameters and snoring data. The medians (min, max) of bruxism group went from 3,11 (2,06; 7,68) to 2,85 (0,00; 9,51). Conclusion : During this study, a reduction of bruxism was observed but a larger sample size is needed to conclude on the subject.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Made available in DSpace on 2016-08-03T16:30:58Z (GMT). No. of bitstreams: 1 Jin Hyun Kim.pdf: 2911975 bytes, checksum: f52f85e0769d576a5d47e7bf335d3973 (MD5) Previous issue date: 2011-10-19 / This study evaluated the skeletal effects of maxillary protraction using 2D images (lateral radiograph) generated from the cone beam CT (3D images). The sample consisted of 20 children (15 females and 5 males), aged 5,6 -10,7 years who had malocclusion Class III malocclusion. CT was performed before treatment (T1) and after treatment (T2). The treatment was performed by maxillary protraction using the Hyrax expansion appliance associated with individualized face mask with the force of 600 to 800g each side for 14 hours a day. The correction of canine relationship in Class I or Class II in their overcorrection was obtained after 4-7 months of treatment. To check the systematic error and random test was used for paired "t" and the formula of Dahlberg, respectively. The test paired "t" (p <0.05) showed a significant difference between the cephalometric measurements obtained in T1 and T2. In the maxilla there were increases in SNA 2.2°, Nperp A 1.47mm and Co-A 2.58mm. In the mandible, SNB decreased by -0.54° and P-Nperp, -1.45mm, while Co-Gn increased 1.04mm. There was improvement in maxillomandibular relationship ANB 2.74° and Wits 4.23mm. Variables GoGn.SN, Gn.SN, FH.Md, Mx.Md and AFAI demonstrating that there was an increased rotation of the mandible in a clockwise direction. The palatal plane rotated in a counterclockwise direction. It can be concluded that the treatment ofmaxillary protraction in early age has promoted an improvement in maxillomandibular relationship due to a shift of the jaw forward and a displacement of the mandible down and back. / Este estudo avaliou os efeitos esqueléticos da tração reversa da maxila utilizando imagens 2D (telerradiografia lateral) geradas a partir da tomografia de feixe cônico (imagens 3D). A amostra foi composta por 20 crianças (15 do gênero feminino, e 5 do masculino), com idade variando de 5,6 a 10,7 anos que apresentavam má-oclusão de Classe III de Angle. A tomografia foi realizada antes do tratamento (T1) e logo após o tratamento (T2). O tratamento foi realizado por meio da tração reversa da maxila utilizando-se o aparelho expansor Hyrax associado à máscara facial individualizada, com força de 600 a 800g de cada lado, durante 14 horas por dia. A correção da relação de caninos em Classe I ou com sua sobrecorreção em Classe II foi obtida após 4 a 8 meses de tratamento. Para verificar o erro sistemático e casual foi utilizado o teste t pareado e a fórmula de Dahlberg, respectivamente. O teste t pareado (p<0,05) mostrou diferença significante entre as medidas cefalométricas obtidas em T1 e T2. Na maxila houve aumento do SNA 2,2°, A-Nperp 1,47mm e em Co-A 2,58mm. Na mandíbula, SNB diminuiu -0,54° e P-Nperp, -1,45mm, enquanto Co-Gn aumentou 1,04mm. Houve melhora na relação maxilo-mandibular ANB 2,74° e Wits 4,23mm. As variáveis GoGn.SN, Gn.SN, FH.Md, Mx.Md, e AFAI aumentaram demonstrando que houve uma rotação da mandíbula no sentido horário. O plano palatino rotacionou no sentido anti-horário. Pode se concluir que o tratamento de tração reversa da maxila na idade precoce promoveu uma melhora na relação maxilo-mandibular devido a um avanço da maxila e um deslocamento da mandíbula para baixo e para trás.

Made available in DSpace on 2016-08-03T16:31:13Z (GMT). No. of bitstreams: 1 FERNANDA CEPERA1.pdf: 1386143 bytes, checksum: e65fb1bc0260136677b2aaa4f7962ade (MD5) Previous issue date: 2009-03-30 / The proposal of the following study was to evaluate the effects of low intensity laser, in the procedure of rapid palatal expansion. 27 individuals were utilized, with age average of 10.2 years-old, splitted in two groups: laser group (n=14), pertaining rapid palatal expansion with laser application, and laserless group (n=13), pertaining only rapid palatal expansion. The expansion bolt activation patttern utilized was 1 complete turn at the first day, and half turn every day until the overcorrection. A diodo laser was utilized (TWIN Laser MMOptics®, São Carlos), according to the following application pattern: wave lenght 780nm, power 40mW, density 10J/cm2, accross 10 spots localized around the median palatine suture. The application stages were: L1 (from first to fifh day), L2 (bolt's lock and the 3 subsequent days), L3, L4 and L5 (after 7, 14 and 21 days after L2, respectively). Occlusal radiographies were taken with the aid of an aluminum scale for densitometric referencial, in different timing: T1 (initial), T2 (bolt's locking day), T3 (3 to 5 days from T2), T4 (30 days from T3), T5 (60 days from T4). The x-ray pictures were digitized and submitted to an image treatment program (Image Tool - UTHSCSA, Texas, USA), for optical density mensuration, on the previsouly selected areas. To realize the statistical tests, it was used the covariance analysis using as covariate the time for the evaluated phase. It all tests it was adopted the significance level of 5% (p<0,05). For the Laser Group the data shows a significant density reduction during the bolt aperture (opening) (T2-T1), a significant density increase in the final evaluation period (T5-T2), and another increase during the regeneration period (T5-T2). From the moment the expander bolt aperture phase ended. While in the Laserless Group the density did not show a statistically significant difference in none of the analyzed periods. The results indicated that the laser generated considerable better openining of the median palatine suture besides the influence in the suture bone regeneration process, accelerating its recovery process.(AU) / A proposta do presente estudo foi avaliar os efeitos do laser de baixa intensidade na regeneração óssea no procedimento de expansão rápida da maxila. Utilizou-se 27 indivíduos com média de idade de 10,2 anos, divididos em dois grupos: grupo laser (n=14), no qual se realizou a expansão rápida da maxila, associada ao laser e grupo sem laser (n=13), que realizou somente a expansão rápida da maxila. O protocolo de ativação do parafuso expansor foi de 1 volta completa no primeiro dia e ½ volta diária até a sobrecorreção. O laser utilizado foi o de diodo (TWIN Laser MMOptics®, São Carlos), seguindo o protocolo de aplicação: comprimento de onda de 780nm, potência de 40mW, densidade de 10J/cm2, em 10 pontos localizados ao redor da sutura palatina mediana. Os estágios de aplicação foram: L1 (do primeiro ao quinto dia de aplicação), L2 (travamento do parafuso e 3 dias seguidos), L3, L4 e L5 (após 7, 14 e 21 dias do L2, respectivamente). Radiografias oclusais da maxila foram realizadas com auxílio de uma escala de alumínio, para referencial densitométrico, em diferentes tempos: T1 (inicial), T2 (dia de travamento do parafuso), T3 (3 a 5 dias do T2), T4 (30 dias do T3), T5 (60 dias do T4). As radiografias foram digitalizadas e submetidas a um programa de imagem (Image Tool - UTHSCSA, Texas, USA), para mensuração da densidade óptica das áreas previamente selecionadas. Para realização do teste estatístico, utilizou-se a Análise de Covariância usando como covariável o tempo para a fase avaliada. Em todos os testes foi adotado nível de significância de 5% (p<0,05).Para o Grupo Laser, os dados mostram que houve uma queda significante de densidade durante a abertura do parafuso (T2-T1), um aumento significante da mesma no período final de avaliação (T5-T4), e um aumento também da densidade no período de regeneração propriamente dito (T5-T2), ou seja, a partir do momento em que finalizou a fase de abertura do parafuso expansor. Enquanto que no Grupo Sem Laser, a densidade não mostrou diferença estatisticamente significantemente em nenhum período analisado. Os resultados mostraram que o laser propiciou consideravelmente uma melhor abertura da sutura palatina mediana, além de influenciar no processo de regeneração óssea da sutura, acelerando seus processos de reparo.(AU)

A expansão rápida da maxila assistida cirurgicamente (ERMAC) é o procedimento de eleição para o tratamento da deficiência transversa de maxila em pacientes esqueleticamente maduros. Controvérsias em relação ao procedimento ainda persistem principalmente relacionadas aos métodos de avaliação, técnica cirúrgica utilizada, morbidade, eficácia clínica e estabilidade de resultados. A utilização da tomografia computadorizada para a avaliação da eficiência da ERMAC é uma opção atual e ainda pouco divulgada. Consequentemente, os parâmetros anatômicos para a utilização deste método ainda não foram totalmente estabelecidos. Os objetivos do presente estudo foram avaliar a confiabilidade da metodologia proposta e as alterações esqueléticas maxilares decorrentes da ERMAC com a utilização do método de avaliação por tomografia computadorizada. No período de junho de 2004 a maio de 2005, 15 pacientes, sendo 10 do sexo feminino, foram submetidos a ERMAC. A técnica cirúrgica utilizada constou de osteotomia maxilar do tipo Le Fort I, sem osteotomia da sutura ptérigo-maxilar, associada a osteotomia sagital mediana do palato. O aparelho expansor utilizado foi do tipo Hyrax. Os pacientes foram submetidos a exames de tomografia computadorizada, em tomógrafos de múltiplos detectores, no pré-operatório e após 6 meses, utilizando-se metodologia idealizada para a avaliação específica deste procedimento cirúrgico. Para a determinação do padrão das alterações transversais e ântero-posteriores, medidas lineares e angulares foram realizadas diretamente na estação de trabalho dos aparelhos de tomografia. Através de imagens obtidas nas aquisições tomográficas axiais e em reconstruções coronais, as regiões anterior, média e posterior da maxila foram avaliadas separadamente. A área de secção transversa da maxila foi também calculada. Após a avaliação dos resultados observou-se que a confiabilidade do método foi estatisticamente comprovada. Um significativo aumento da área de secção transversa da maxila foi observado (p<0.05). Entretanto, o padrão de expansão transversa não se mostrou uniforme. O aumento das dimensões transversas nas regiões anterior e média foi estatisticamente comprovado. Não foi observada expansão transversa significativa na região posterior da maxila. Ao se avaliar a relação entre a abertura do parafuso expansor e a efetiva expansão esquelética da maxila, observou-se que esta foi menor que a abertura do parafuso, em termos absolutos. O aumento transverso relativo à expansão do parafuso foi estatisticamente maior nas regiões anterior e média da maxila do que em sua região posterior. Em conclusão, a avaliação por tomografia computadorizada para a análise das alterações esqueléticas da região maxilar, em pacientes submetidos à ERMAC é metodologia confiável e reprodutível. A expansão transversa da maxila decorrente do procedimento de ERMAC utilizado no presente estudo acarretou uma expansão não uniforme da maxila, com predomínio da expansão transversa nas regiões anterior e média. / Surgically assisted rapid palatal expansion is the procedure of choice for treating transverse maxillary deficiency in mature patients. Some controversies regarding surgically assisted rapid palatal expansion remain, mainly concerning technical aspects such as type and location of osteotomy sites, as well as surgical morbidity, clinical efficiency, and stability. The evaluation of transverse expansion is still a theme of discussion. On conventional anteroposterior radiographs, anatomical structures are superimposed, resulting in a high number of image artifacts, as well as hindering the tracing and evaluation. The use of computed tomography as a method of evaluating the efficiency of this procedure has not been widely reported. Consequently, few landmarks for use in evaluating maxillary expansion have been defined. The goals of the present study were to define parameters to assess skeletal changes after surgically assisted palatal expansion, to evaluate the reliability of the proposed method and to use computed tomography to assess those parameters. From June of 2004 to May of 2005, 15 patients underwent surgically assisted rapid palatal expansion (a modified Le Fort I maxillary osteotomy without pterygomaxillary separation, together with a sagital palatal osteotomy) according to a defined protocol, using a Hyrax appliance. To determine the pattern of transversal and anteroposterior expansion, linear and angular measurements were performed on multislice computed tomography, using computed software directly on the workstation. The anterior, intermediate and posterior portions of the maxilla were evaluated separately, using a specific method, in axial acquisition and coronal reconstructed views. The cross-sectional area of the maxilla was calculated to obtain general information about maxillary expansion. The reliability of the method was statistically confirmed. Significant maxillary overall expansion was observed. However, different patterns of expansion were seen in the three regions analyzed. In the anterior and intermediate portions of the maxilla, the increase in maxillary width was significantly greater than that observed in the posterior portion. The opening of the jackscrew was greater than skeletal expansion. Comparing jackscrew opening and transverse expansion, the same pattern of asymmetric expansion was verified. No change was observed in anteroposterior dimensions. The method of computed tomography evaluation is a useful tool for evaluation of surgically assisted rapid palatal expansion changes. The accurate evaluation of the postoperative changes was heavily dependent upon images acquired through computed tomography. An overall maxillary expansion was confirmed. However, transverse expansion of the maxilla achieved through surgically assisted rapid palatal expansion without pterygoid plate separation was less than uniform.