Prostorove pomeï ry v distaâ lnõâm uâ seku dolnõâho oblouku Space in the distal region oflower arch

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1 ORTODONCIE rocïnõâk19 Prostorove pomeï ry v distaâ lnõâm uâ seku dolnõâho oblouku Space in the distal region oflower arch * MUDr. Bc. ZdeneÏ k Haken, * MUDr. Hana TycovaÂ, ** Mgr. KaterÏina Langova * Ortodonticke oddeï lenõâ, Stomatologicka klinika1.lfuk avfn v Praze * Department of Orthodontics, Clinic of Dental Medicine, 1st Medical Faculty of Charles University in Prague ** Katedra leâkarïskeâ biofyziky, LF UP Olomouc ** Department of Medical Biophysics, Medical Fakulty, Palacky University in Olomouc Souhrn Je pojednaâ n vyâ voj prostoru v lateraâ lnõâm uâ seku dolnõâho oblouku. Byla provedena analyâ za prostoru distaâ lneï od prvnõâho staâleâ ho molaâ ru. Byl sledovaâ n lineaâ rnõâ parametr Ar-Pg, uâ hly ANB a Goniovy uâ hel. Do souboru byli zarïazeni jedinci, u kteryâ ch byly k dispozici dva kefalometrickeâ snõâmky, zhotoveneâ v obdobõâ prïed a po pubertaâ lnõâm ruê stoveâ m spurtu. CõÂlem praâ ce bylo vyhodnotit velikost zmeï ny meï rïenyâ ch lineaâ rnõâch a uâ hlovyâ ch parametruê po probeï hleâ m pubertaâ lnõâm ruê stoveâ m spurtu a zjistit, zda existuje zaâ vislost mezi meïrïenyâ mi parametry na dolnõâ cï elisti a prostorem distaâ lneï od prvnõâho staâ leâ ho molaâ ru. Po probeï hleâmruê stoveâ m spurtu bylo zjisïteï no statisticky vyâ znamneâ zmensï enõâ GonioveÂhou hlu a uâ hlu ANB. Byla prokaâzaâ na korelace mezi velikostõâ zmeï ny Ar-Pg a prostorem distaâ lneï od prvnõâho dolnõâho molaâ ru. Korelace mezi velikostõâ zmeï ny Goniove ho uâ hlu, uâ hlu ANB a prostorem distaâ lneï od prvnõâho dolnõâho molaâ ru nebyla prokaâ zaâ na (Ortodoncie 2010, 19, cï. 3, s ). Abstract The space development laterally in the lower arch was discussed. The space analysis was performed in the region distally from the first permanent molar. The linear parameter Ar-Pg, angles ANB and Gonion were registered. The sample included patients with two cephalograms - one taken prior and the other after the growth spurt. The aim of our work was to assess the change of linear and angular parameters after the growth spurt, and try to find out the relation between the measured parameters in the mandible and the space distally from the first permanent molar. After the finished growth spurt we indicated statistically significant decrease of the Gonion and ANB angles. The correlation between the change Ar-Pg, and the space distally from the first lower molar was proved. The relation between the change of Gonion, ANB angles and the space distally from the first lower molar was not found (Ortodoncie 2010, 19, cï. 3, s ). KlõÂcÏ ovaâ slova: distaâ lnõâ steï snaâ nõâ, prostorovaâ analyâ za, erupce druheâ ho molaâ ru. Key-words: distal crowding, space analysis, second molar eruption redakce@orthodont-cz.cz 27

2 rocïnõâk19 ORTODONCIE U vod Pro posouzenõâ prostorovyâ ch pomeï ruê ve staâ leâ m chrupu pouzïõâvaâ me metody segmentaâ lnõâ analyâzy saâ d- rovyâch modeluê. Ve smõâsï eneâ m chrupu maâ me k dispozici Moyersovu analyâzu. TõÂmto postupem muêzï eme s urcïitou pravdeï podobnostõâ posoudit dostatecï nost prostoru, kteryâ maâ me k dispozici pro prorïezaâ nõâ postrannõâho uâ seku chrupu. Jedna sevsï ak pouze o prostor vymezenyâ prïed prvnõâm staâlyâm molaâ rem. Prostor distaâ lneï od prvnõâho staâ leâ ho molaâ ru neï kdy unikaâ pozornosti. Ve staâleâ m chrupu si jej cï asto vsïõâmaâmeazï s potrïebou rïesï it neprïõâznivou situaci. Ve druheâ etapeï vyâmeï ny chrupu, ani v pocï aâ tecï nõâch staâ diõâch erupce druheâ ho staâ leâ ho molaâ ru, nemaâ prostor za prvnõâm staâ lyâ m molaâ rem definitivnõâ velikost. NavõÂc v tomto prostoru se veïtsï inou nachaâ zõâ vedle druheâho molaâruizaâ rodek trïetõâho molaâ ru. K retenci dochaâ zõâ nejcï asteï jiutrïetõâch dolnõâch molaâ ruê. K retenci druheâ ho staâ leâ ho molaâ ru dochaâ zõâ naopak zrïõâdka, Prece [1] uvaâ dõâ prevalenci 0,06 %. Druhy molaâ r maâ i z hlediskaevoluce svuê j prostor v chrupu vymezen. K retenci druheâ ho molaâ rumuê zï e dochaâ zet zaokolnostõâ, jejichzï podstata je znaâ maâ, jindy vsï ak pravou podstatu tohoto neprïõâzniveâ ho jevu spõâsï e odhadujeme. CõÂlem teâ to praâ ce je proveâ st prostorovou analyâzu v zubnõâm oblouku dolnõâ cï elisti, distaâ lneï od prvnõâho staâleâ ho molaâ ru. Pro analyâ zu bylavybraâ naobdobõâ prïed apo pubertaâ lnõâm ruê stoveâ m spurtu. Byl sledovaâ n lineaâ rnõâ znak Ar-Pg a uâ hly ANB ago uâ hel. MeÏrÏen byl i prostor distaâ lneï od prvnõâho dolnõâho molaâ ru, oznacï enyâ jako Dist. U kolem praâ ce je vyhodnotit velikost zmeïnymeïrïenyâch lineaâ rnõâch auâ hlovyâ ch parametruê po probeï hleâ m pubertaâ l- nõâm ruê stoveâ m spurtu. DalsÏ õâm cõâlem je stanovenõâ korelace mezi zmõâneï nyâ mi parametry a prostorem distaâ lneï od prvnõâho staâleâ ho molaâ ru, znakem Dist. Introduction The evaluation of space condition in permanent dentition the segmental analysis on models is used. In mixed dentition the Moyers analysis is necessary. Using these methods we can judge the space sufficiency after eruption of lateral teeth. However, this is only the space in front of the first permanent molar. Sometimes the space behind the first permanent molar is paid less attention. In permanent dentition, we often take it into the consideration only if we have to solve some unfavourable situation. During the second phase of change of dentition as well as in the early stages of second permanent molar eruption the space beyond the first permanent molar does not have the final size. Moreover, in the space is often found not only the second molar but also the third molar germ. The impacted teeth are most often the lower third molars. On the other hand, the impaction of second permanent molar is rather rare. Prece [1] gives prevalence of 0.06%. The space for the second molar in dentition is determined also from the evolutionary viewpoint. The impaction of second molar may occur sometimes under the known circumstances; however, sometimes we cannot determine the cause. This study aims to make the space analysis of the lower dental arch, distally off the first permanent molar. The analysis was performed before and after the growth spurt. We monitored the linear parameter Ar- Pg and ANB and Go angles. We also measured the space located distally off the lower first molar (Dist). The aim of the study was to evaluate the changes in linear and angular parameters after the finished growth spurt, and to find the correlation between the parameters given above and the space located distally off the first permanent molar (Dist). Materia l a metodika Do souboru byli zarïazeni pouze pacienti, u kteryâch byl zhotoven profilovyâ rentgenovyâ snõâmek v obdobõâ prïed spurtem (shoraohranicï eno stadiem CVMS II, vcï etneï ) av obdobõâ po ruê stoveâ m spurtu ( zdolaohranicï eno stadiem CVMS IV, vcï etneï ). Pro urcï enõâ stadia vyzraâ vaâ nõâ skeletu bylapouzï itamodifikovanaâ metoda hodnocenõâ krcï nõâch obratluê podle Baccettiho [2, 3]. VeÏkove rozmezõâ ve sledovaneâ m souboru bylo 7-18 let PruÊ meï rnyâ veï k pacientuê v obdobõâ prïed ruê stovyâ m spurtem byl 9,9 roku apo spurtu 14,7 roku. Za kladnõâ vyâbeï r cï õâtal 134 pacientuê, kterïõâ splnï ovali podmõânku dvou daâ lkovyâ ch rentgenuê zhotovenyâch ve zmõâneï nyâch ruê stovyâch faâ zõâch. Z tohoto zaâ kladnõâho vyâbeï ru byli vyrïazeni pacienti, u kteryâ ch bylauskutecï neï naextrakcï nõâ leâ cï ba.daâ le byly vyrïazeny rentgenoveâ snõâmky, u kteryâ ch nebylo mozï no Material and method Only the patients with a lateral cephalometric pictures before the growth spurt (upper limit stated as CVMSII stage inclusive), and after the growth spurt (lower limit set at CVMS IV, inclusive). To determine the stage of skeletal development, we used a modified evaluation of cervical vertebrae according to Baccetti [2, 3]. The age range was 7-18 years. The mean age of patients before the growth spurt was 9.9 years, and after the growth spurt 14.7 years. At the beginning 134 patients were chosen; later the patients who underwent extractions were left out, as well as X-rays of an insufficient quality. The sample consisted of 80 patients treated with fixed appliances at the Department of Orthodontics, 1st Medical Faculty Charles University in Prague. There were 22 males and 58 females in the sample redakce@orthodont-cz.cz

3 ORTODONCIE rocïnõâk19 z duê vodu nõâzkeâ technickeâ kvality spolehliveï odecïõâst meïrïeneâ znaky. Soubor byl sestaven z 80 jedincuê leâ cï enyâ ch fixnõâm aparaâ tem naortodontickeâ m oddeï lenõâ 1. LFUK avfn v Praze. Ve sledovaneâ m souboru bylo 22 muzïuê a58 zïen. PrÏed vlastnõâm meïrïenõâm byla provedena digitalizace vsï ech kefalometrickyâ ch snõâmkuê. PouzÏ it byl skener Epson Perfection V700 Photo s optickyâ m rozlisï enõâm 6400 x 9600 dpi. Pro vyâstup namonitor bylo zvoleno maximaâ lnõâ rozlisï enõâ 100 dpi. Analy zabylaprovaâ deï na nagrafickeâ m monitoru EIZO 22º model S2242W s vysokyâm rozlisï enõâm 1920x1200 boduê. Takto digitalizovaneâ snõâmky byly zpracovaâ ny pomocõâprogramu PCdent Ò, spolecï nosti Dialog MIS a pomocõâ Excelu sady MS Office KazÏdy rentgenovyâ snõâmek byl prïed analyâ zou kalibrovaâ n pomocõâ referencï nõâ vzdaâ lenosti ameï rïõâtka. Za kladem pro odvozenõâ metodiky teâ to praâ ce se stala Rickettsova ruê stovaâ analyâ zadolnõâ cï elisti [4]. Jako referencï nõâ body byly prïi analyâ ze rentgenovyâ ch snõâmkuê vyuzï ity beï zï neï pouzï õâvaneâ konstruovaneâ aantomickeâ kefalometrickeâ body [4, 5, 6]. Z uâ hlovyâ ch rozmeï ruê byl meï rïen Goniovy uâ hel auâ hel ANB. De lku dolnõâ cï elisti prïedstavoval rozmeï r Ar-Pg. Z boduê aliniõâ, ktereâ nejsou beï zï nou soucï aâ stõâ nejcï a- steï ji pouzï õâvanyâ ch analyâ z vyjõâmaâ me zejmeâ na: SPo (suprapogonion) - bod nachaâ zejõâcõâ se naanteriornõâm povrchu symfyâ zy, Ricketts jej umõâstil do oblasti kde konvexitakosteï neâ ho bradoveâ ho vyâbeï zïku prïechaâzõâ v konkavitu, mezi body B a Po. Prakticky se ukaâ zalo, zïe pro jeho nejprïesneï jsï õâ stanovenõâ je vyâ hodneâ pouzï õât kraniaâ lnõâ okraj hrïebene kompakty, kteraâ ventraâ lneï ohranicï uje symfyâ zu. Xi (bod Xi) - konstruovanyâ bod naveï tvi dolnõâ cï elisti, nachaâ zejõâcõâ se mezi nebo naneï ktereâ z kontur mandibulaâ rnõâho kanaâ lu (konstrukce modifikovaneâ ho bodu Xi - Obr. 1) M (bod M) - konstruovanyâ bod vznikajõâcõâ proteïtõâm kolmyâ ch liniõâ V-ref. ah-ref. (Xi-SPO) v mõâsteï nejdistaâ l- neï jsï õâho okraje korunky dolnõâho prvnõâho molaâ ru (Obr. 1) Popis modifikovaneâ konstrukce bodu Xi: Modifikace puê vodnõâ Rickettsovy metodiky spocïõâvaâ ve volbeï odlisï neâ referencï nõâ linie. Ricketts pouzï il Frankfurtskou horizontaâ lu, cozï z duê vodu nedostatecï neâ reprodukovatelnosti nebylo pro nasïe uâcï ely akceptovatelneâ.v teâ to praâ ci bylapouzï italinie S-N, kterou lze urcï it s dostatecï nou prïesnostõâ. Vlastnõ konstrukce bodu Xi probõâhala v neï kolikakrocõâch. Nejprve sestrojenõâ tecï ny k nejinferiorneï jsïõâmu bodu incisura mandibulae, kteraâ je soucï asneï paralelnõâ s liniõâ S-N. Da le sestrojenõâ prïõâmky paralelnõâ s liniõâ S-N tak, aby tvorïilatecï nu k dolnõâmu okraji hrany mandibuly v mõâsteï, kde konvexitauâ hlu mandibuly prïechaâ zõâ v kon- Before the measurement all cephalograms were digitalized. We used scanner Epson Perfection V700 Photo, resolution 6400 x 9600 dpi. For the monitor output the maximum resolution of 100 dpi was selected. The analysis was performed on the graphic screen EIZO 22º, model S2242W, high-definition resolution 1920 x 1200 dpi. The digitalized pictures were processed with PCdent Ò software, Dialog MIS, and with Excel of MS Office Before the analysis, each X-ray was calibrated with reference distance and scale. Ricketts growth analysis of the mandible served as the basic model for the method used in our study [4]. Constructed and anatomical cephalometric points [4, 5, 6] were used as reference points in the cephalometric analysis. Gonion angle and the angle ANB were used from angular measurements. Linear distance Ar-Pg showed the length of the mandible. Following are the points and lines which are not used so frequently: SPo (suprapogonion) - the point on the anterior surface of symphysis. Ricketts located the point in the area where convexity of mental protuberance transfers into concavity, i.e. between the points B and Po. The most accurate results are obtained by the use of cranial edge of cortical crest, ventrally surrounding symphysis. Xi (point Xi) - the constructed point on the mandible ramus, found between (or on some of) the contours of the mandible channel (for the construction of the modified point Xi - Fig. 1). M (point M) - the constructed point at the crossing of perpendicular lines V-ref. and H-ref. (Xi-SPO) at the place of the most distal surface of the crown of the lower first molar (Fig. 1). Modified construction of Xi point: The modification of the Ricketts method is based on the choice of adifferent reference line. Ricketts employed Frankfurt horizontal. However, this was not acceptable for our work due to insufficient reproducibility. Therefore, we used S-N line in our work as this line may be determined with sufficient accuracy. The construction of Xi point involved several steps. First we plotted atangent to the most inferior point of mandibular notch that goes parallel with S-N line. Then we drew a straight line parallel with S-N line, so that it became the tangent to the lower border of the mandible at the place where convexity of the mandible angle transforms into concavity of the lower border of the mandible. Finally, we plotted tangents to the anterior and posterior concavity of the mandible ramus perpendicular to S-N line. redakce@orthodont-cz.cz 29

4 rocïnõâk19 ORTODONCIE kavitu dolnõâ hrany mandibuly. Sestrojenõ tecï en k prïednõâ a zadnõâ konkaviteï ramene mandibuly tak, aby byly kolmeâ k linii S-N. PruÊ secï õâk uâ hloprïõâcï ek takto zkonstruovaneâ ho obdeâ l- nõâku je bodem Xi. Nacha zõâ se vzï dy mezi konturami mandibulaâ rnõâho kanaâ lu nebo naneï ktereâ z nich, v pomyslneâ m strïedu ramene mandibuly. Zaza klad konstrukce referencï nõâch liniõâ bylatakteâ zï vzata puê vodnõâ Rickettsovapra ce [4]. Konstruovane linie H-ref. (horizontaâ lnõâ referencï nõâ linie, Xi-SPo) -horizontaâ lnõâ referencï nõâ linie zvolenaâ pro tuto praâ ci, konstruovanaâ jako spojnice boduê Xi aspo. Ve sveâ podstateï tato linie vyjadrïuje osu teï ladolnõâ cï elisti. V-ref. (vertikaâ lnõâ referencï nõâ linie) - konstruovanaâ jako kolmice nalinii Xi-SPo v bodeï M (Obr. 1). Pro zvolenou metodiku je duê lezï iteâ, zï e bylanavrzï ena aupravenatak, aby co nejleâ pe postihlaprostor alveolu dolnõâ cï elisti, tj. prostor ve ktereâ m se prorïezaâ vajõâ zaâ rodky druhyâ ch a trïetõâch staâ lyâ ch molaâ ruê. Proto byl konstruovaâ n bod M, kteryâ dle nasï eho naâ zoru, je v nejteï sneïjsï õâ souvislosti s osou teï ladolnõâ cï elisti ajeho prostoroveâ zmeïny tak nejleâ pe odpovõâdajõâ skutecï nyâ m prostorovyâ m zmeïnaâ m ve vyvõâjejõâcõâm se zubnõâm oblouku. Tyto zmeï ny jsou pak vyjaâdrïeny zmeï nou vzdaâ lenosti boduê Xi am abyly vteâ to praâcioznacï eny jako znak Dist. MeÏ rïenõâ vsï ech znakuê bylo provaâdeï no nadvou profilovyâ ch rentgenogramech, zarïazenyâ ch dle selekcï nõâch kriteriõâ teâ to praâ ce. Prvnõ byl zhotoven prïed ruê stovyâm Obr. 1: Konstrukce modifikovaneâ ho bodu Xi areferencï nõâch liniõâ Fig. 1: Construction of the modified Xi point and reference lines The intersection of diagonals of the rectangle thus construed is Xi point. It is always between the contours of mandible channel or in some of them, in the middle of the mandible ramus. Ricketts method [4] became also the basis for the construction of reference lines. Constructed lines H-ref. (horizontal reference line, Xi-SPo) - horizontal reference line used in our work, and constructed as the connecting line of the points Xi and SPo. The line represents the axis of the mandible body. V-ref. (vertical reference line) - constructed as the perpendicular to Xi-SPo line at the point M (Fig. 1). The method should be designed and modified so that it represents as best as possible the space in the alveolar process, i.e. the space where the second and third permanent molar germs erupt. Therefore, the point M was constructed, as it relates to the axis of the mandible body, and the space changes of the point best correspond to the actual space changes in the developing dental arch. The changes are then expressed as the change of distance between Xi and M points (i.e. Dist.). All parameters were measured in two profile cephalometric pictures included into the analysis according to the given criteria. The first picture was taken prior to the growth spurt (the parameter measured was marked as 1), and the second one after the finished growth spurt (the parameter measured was marked as 2). Statistical data were processed with the help of SPSE software, version 16. All parameters, with the exception of Ar-Pg2 and ANB1, showed normal distribution. The data with abnormal distribution were also processed in pairs (Ar- Pg1 and Ar-Pg2, ANB1 and ANB2). Therefore, we used parameter tests (Student's pair t-tests). However, the results were verified and proved with non-parametric methods (Wilcoxon tests). Using correlation analysis, we tried to find the relationship between individual parameters observed (change in Go angle, change of Ar-Pg, and change in ANB) and the change of the distance Dist. The correlation analysis was performed as the calculation of Pearson's correlation coefficients. The correlation was considered as significant on the level of p < By repeated measurements of selected parameters in 44 patients, we stated the mean error of measurement of angular parameters 0.28, and of linear parameters 0.28 mm. Results Growth spurt led to the mean reduction of Go angle by ±1.74 (± 3.74 ), ANB angle by ±1.44 (± 1.53 ) (Table 1) redakce@orthodont-cz.cz

5 ORTODONCIE rocïnõâk19 pubertaâ lnõâm spurtem (oznacï enõâ meï rïeneâ ho znaku 1) adruhyâ po ruê stoveâ m pubertaâ lnõâm spurtu (oznacï enõâ meïrïeneâ ho znaku 2). Zpracova nõâ statistickyâ ch dat bylo provedeno pomocõâ programu SPSE verze 16. VsÏ echny znaky, kromeï Ar-Pg2 a ANB1, vykazovaly normaâ lnõâ rozlozï enõâ. Vzhledem k tomu, zï e i data, kteraâ nemeï lanormaâ lnõâ rozlozï enõâ, bylazpracovaâ vaâ na paâ roveï (Ar-Pg1 aar-pg2; ANB1 aanb2) byly ke zpracovaânõâ pouzï ity parametrickeâ testy (Studentovy paâ roveâ t-testy). Vy sledky byly vsï ak oveï rïeny apotvrzeny pomocõâ neparametrickyâch metod (Wilcoxonovy testy). Da le bylapomocõâ metod korelacï nõâ analyâ zy hledaâ na zaâ vislost mezi jednotlivyâ mi sledovanyâ mi znaky (zmeï na Go, zmeï naar-pg azmeï naanb) azmeï nou Dist. KorelacÏ nõâ analyâ zabylaprovedenavyâ pocï tem Pearsonovy ch korelacï nõâch koeficientuê. Korelace byla povazï ovaâ na za signifikantnõâ na uâ rovni p < 0,01. Opakova nõâm meï rïenõâ vybranyâ ch znakuê u 44 jedincuê bylastanovenapruê meï rnaâ chybameï rïenõâ pro uâ hloveâ znaky 0,28 apro lineaâ rnõâ znaky 0,28 mm. Vy sledky RuÊ stovyâm spurtem dosï lo k pruêmeï rneâ mu zmensï enõâ hodnoty Go uâ hlu o ±1,74 (± 3,74 ), daâ le v tomto obdobõâ dosï lo k pruê meï rneâ mu zmensï enõâ hodnoty uâ hlu ANB o ±1,44 (± 1,53 ) (Tab. 1). PruÊ meï rnaâ zmeï naar-pg dosaâ hlahodnoty + 9,98 mm (± 3,84mm) (tab. 2). Studentovy mi paâ rovyâ mi t-testy bylo prokaâ zaâ no, zï e po probeï hleâmruê stoveâ m spurtu dosï lo k statisticky vyâznamneâ mu snõâzï enõâ hodnot uâ hluê Go (p = 0,0001) aanb (p < 0,0001) ake statisticky vyâ znamneâ mu zvyâ- The mean change of Ar-Pg was mm (± 3.84 mm) (Table 2). Student's pair t-tests proved that after the finished growth spurt the values of angles Go (p = ) and ANB (p < ) showed statistically significant decrease, while the parameters Dist. and Ar-Pg (p < in both) showed statistically significant increase. Verification of the results for parameters Ar-Pg and ANB with Wilcoxon serial tests proved the conclusions. The correlation analysis was performed as the calculation of Pearson's correlation coefficients. It was proved that between the values change Dist, and change Ar-Pg exists statistically significant medium size positive correlation (Table 4). The situation is illustrated with a dot chart (Fig. 2) with a regressive straight line illustrating the tendency of the relationship. There was found no statistically significant correlation between the other parameters and the change in Dist. Discussion Growth represents an important factor influencing the final sagittal position of jaws. Of course, the growth of jaws affects dental relationship of the upper and lower dental arches. Increasing jaws bases should be accompanied with sufficient increase of space for inclusion of all teeth. Whenever we evaluate dental discrepancy and plan the resulting intercuspation we should take into account the dynamics of the jaws development. Tabulka 1: U hloveâ rozmeïry Table 1: Angle measurements Tabulka 2: Linea rnõâ parametry Table 2: Linear parameters N - pocï et, number, Min. -minimaâ lnõâ hodnota, minimum value, Max. - maximaâ lnõâ hodnota, maximum value, Mean - pruêmeï r, SD - smeï rodatnaâ odchylka, standard deviation redakce@orthodont-cz.cz 31

6 rocïnõâk19 ORTODONCIE sï enõâ hodnot parametruê Dist aar-pg (p < 0,0001 v obou prïõâpadech). Validizace vyâsledkuê pro parametry Ar-Pg a ANB WilcoxonovyÂmi porïadovyâmi testy tyto zaâveï ry potvrdila. KorelacÏ nõâ analyâ zabylaprovedenavyâ pocï tem Pearsonovy ch korelacï nõâch koeficientuê. Bylo prokaâ zaâ no, zï e mezi velicï inami zmeï nadist azmeï naar-pg je statisticky vyâ znamnaâ strïedneï silnaâ pozitivnõâ zaâ vislost (viz. Tabulka 4). Situace je znaâ zorneï nabodovyâm grafem (Obr. 2) s prolozï enou regresnõâ prïõâmkou naznacï ujõâcõâ trend tohoto vztahu. Mezi ostatnõâmi znaky a znakem zmeï nadist statisticky vyâznamnaâ korelace nalezena nebyla. Diskuse Pro konecï neâ sagitaâ lnõâ postavenõâ cï elistõâ maâ velkyâ vyâznam ruê st. RuÊ st cï elistõâ se bude samozrïejmeï promõâtat i do dentaâ lnõâho vztahu hornõâho a dolnõâho zubnõâho oblouku. Se zveïtsï ovaânõâm baâzõâ cï elistõâ ocï ekaâvaâ me dostatecï nyâ prïõâruê stek prostoru pro zarïazenõâ vsï ech zubuê. PrÏi hodnocenõâ dentaâ lnõâ diskrepance i prïi plaâ novanõâ vyâ sledneâ artikulace je nutneâ s dynamikou vyâvoje cï elistõâ pocïõâtat. The space before the lower first permanent molar was evaluated by Moyers [5] and others [6, 7, 8, 9, 10]. The space behind the lower first permanent molar was dealt with - in relation to the inclusion of third molars - by Richardson [12, 13], Bishara [14], Zachrisson [15], Sable [16], Ledyard, Kaplan and a number of other authors. The development of the space for the inclusion of teeth in the mandible during the growth spurt was the goal of our study, i.e. it dealt with the period when the space for the inclusion of second and third permanent molars is created. The sample of our patients was selected according the skeletal growth stage. The sample consisted of 72% girls, and 28% boys. This difference in number is due to the difference in skeletal maturation related to sex. The eruption of second molars and finished treatment very often did not coincide with CVMS IV stage in boys. The growth spurt in boys was not finished very often with erupted second molars, and therefore, these patients could not be included in the sample. Tabulka 3: ZmeÏ ny ajejich signifikace Table 3: Changes and significance s x - strïednõâ chybapruêmeï ru, standard error of the mean, t - StudentuÊ v t-test, Student t-test Tabulka 4. KorelacÏ nõâ koeficienty mezi zmeï nami sledovanyâch znakuê azmeï nou Dist. Table 4. Correlation coefficients between changes of parameters ane the change in Dist. ** Korelace je signifikantnõâ na hladineï vyâznamnosti 0.01, correlatiom is sigmificant on the level 0.01 Ve smõâsï eneâ m chrupu se hodnocenõâm prostoru prïed prvnõâm staâlyâm dolnõâm molaâ rem zabyâval Moyers [5] aneï kterïõâ dalsï õâ autorïi [6,7,8,9,10]. Prostor zadolnõâm prvnõâm staâ lyâ m molaâ rem zkoumali, zejmeâ naz hlediska zarïazenõâ trïetõâch molaâruê, Richardson [12, 13], Bishara [14], Zachrisson[15], Sable [16], Ledyard, Kaplan amnozõâ dalsïõâ. Tato praâ ce bylazameï rïenanavyâ voj prostoru pro zarïazenõâ zubuê v dolnõâ cï elisti v pruêbeï hu pubertaâ lnõâho ruêstoveâ ho spurtu, tj. naobdobõâ, kdy se mimo jineâ utvaârïõâ prostor pro zarïazenõâ druhyâch atrïetõâch staâlyâch molaâruê. JednõÂm z hlavnõâch kriteriõâ vyâbeï ru do souboru bylo ruêstoveâ staâ dium skeletu. KonecÏ nyâ analyzovanyâ soubor tvorïilo 72 % dõâvek a28 % chlapcuê. Tento nepomeïr je vyjaâdrïenõâm odlisï nosti ve vyzraâvaâ nõâ skeletu v zaâ vislosti Obr. 2: Korelace mezi zmeï nou Ar-Pg azmeï nou rozmeï ru Dist. Fig. 2: Correlation between the change in Ar-Pg and the change of Dist redakce@orthodont-cz.cz

7 ORTODONCIE rocïnõâk19 napohlavõâ. ProrÏeza nõâ druhyâ ch molaâ ruê adokoncï enõâ leâcï by se u chlapcuê cï asto neshodovalo s prïõâtomnostõâ staâ diacvms IV. RuÊ stovyâ spurt u chlapcuê s prorïezanyâmi druhyâmi molaâ ry nebyl tedy veïtsï inou dokoncïen atito jedinci museli byât vyrïazeni ze souboru. PrÏi mõârneâ anteriorotaci, cozï je nejcï asteï jsïõâ ruê stovyâ typ, dochaâ zõâ k ¹zavõÂraÂnõªGou hlu azaâ rovenï k zmensïovaânõâuâ hlu ANB. VeÏ tsï inaautoruê kefalometrickyâ ch analyâ z pouzï õâvaâ vlastnõâ interval a pruê meï r hodnot GonioveÂho uâ hlu: Hasund 123 (± 7,2), Jarabak 130 (± 7), Williams 126 (± 6). StrÏednõ hodnotagonioveâ ho uâ hlu vyplyâ vajõâcõâ z meï rïenõâ vteâ to praâ ci (Tabulka 1) se nejvõâce blõâzïõâ HasundoveÏ analyâ ze. PrÏed spurtem, pruê meï r 122,95 ±6,0. Po spurtu, pruêmeï r 121,21 ±6,5. V pruêbeïhu ruê stoveâ ho spurtu se uveïtsï iny populace hodnota Go uâ hlu zmensï uje. Tato skutecï nost s sebou nese i zmeï nu polohy dolnõâ cï elisti. Bod B rotuje smeï rem vprïed, meï nõâ se velikost uâ hlu ANB. Richterova [17] ve sveâ praâ ci nameï rïilananeleâ cï eneâ kontrolnõâ skupineï, v obdobõâ mezi 11. a15. rokem, pokles GonioveÂho uâ hlu pruê meï rneï o 1,89. Toto zmensï enõâ lze prïicï õâst zmeï neï polohy dolnõâ cï elisti zpuê sobeneâ jejõâ rotacõâ aodlisïneâ mu tempu v ruê stu maxily a mandibuly. Z toho plynoucõâ vliv nadentaâ lnõâ okluzi je zrïejmyâ. Interval a pruêmeï r hodnot uâ hlu ANB v jednotlivyâch analyâzaâ ch se nelisï õâ tolik, jako je tomu u GonioveÂho uâ hlu. Hasund 2,3 (± 1,8), Jarabak 2 (± 3), Williams 3 (± 1,3). StrÏednõ hodnotauâ hlu ANB vyplyâvajõâcõâ z meïrïenõâ v teâ to praâ ci (Tabulka cï. 1) se opeï t nejvõâce blõâzïõâhasundoveï analyâ ze. PrÏed spurtem, pruê meï r 3,5 ±2,7. Po spurtu, pruêmeï r 2,1 ±2,4. Dibbets [18] pouzïil pro meïrïenõâ prïõâruê stkuê vdeâ lce dolnõâ cï elisti vzdaâ lenost Ar-Pg. Tato metodika se ukaâ zala jako nejleâ pe reprodukovatelnaâ. Z Rickettsovy praâ ce [5] bylo odvozeno meï rïenõâ vzdaâlenosti Xi-M oznacï eneâ jako znak Dist (prostor distaâ lneï zaprvnõâm dolnõâm molaâ rem). PruÊ meï rnaâ zmeï nadist (Xi- M) byla+7,75 (± 2,90 mm). Forsberg [19] uvaâ dõâ pruêmeïrnou velikost druheâ ho staâ leâ ho dolnõâho molaâ ru u muzïuê 11,00 mm (± 0,50 mm) a10,20 mm (± 0,49 mm) u zïen. Z toho lze usuzovat, zïe znacïnaâcïaâ st prostoru pro prorïezaânõâ teï chto zubuê vznikaâ resorpcõâ prïednõâho okraje ramus mandibulae. Prostor pro zarïazenõâ druheâ ho dolnõâho molaâ ru, kteryâ se dotvaâ rïõâ v pruê beï hu ruê stoveâ ho spurtu, je svou velikostõâ teï sneï proporcionaâ lnõâ k velikosti tohoto zubu. PouzÏ ijeme-li v ortodontickeâ leâ cï beï mechaniku, kteraâ tento prostor vyâ znamneï vyuzï õâvaâ pro rïesï enõâ steï snaâ nõâ, lze se domnõâvat zï e snaâzemuêzïe dojõât k retenci druhyâch molaâruê,trïetõâ molaâ ry s nejveïtsï õâ pravdeï podobnostõâ zuê stanou retinovaâ ny. ZaÂveÏr Bylo analyzovaâ no 160 bocï nõâch kefalogramuê u 80 jedincuê v pruêbeïhu ruê stoveâ ho spurtu. Po probeï hleâm ruê- The mild anteriorotation, which is the most frequent growth type, ¹closesª the Go angle and reduces the ANB angle. Most authors of cephalometric analyses use their own interval and mean value of Gonion angle: Hasund 123 (± 7.2), Jarabak 130 (± 7), Williams 126 (± 6). The mean value of Gonion angle obtained through our measurements is similar to that given by Hasund (Table 1). Before the growth spurt: 123 ±6.0; after the finished growth spurt: 121 ±6.5. The Go angle usually decreases in population during the growth spurt. This fact brings about also changes in the position of the mandible. The point B rotates in anterior direction, and ANB angle value changes, too. In her work, Richter [17] measured Gonion angle in the control (untreated) group, and reported the mean reduction by 1.89 in the period between the age of 11 and 15. The decrease is probably due to the change in the mandible position caused by its rotation, and due to the different rate in the growth of the maxilla and the mandible. This, of course, affects dental occlusion. The interval and mean value of ANB angle is not so different in individual analyses: Hasund 2.3 (± 1.8), Jarabak 2 (± 3), Williams 3 (± 1.3). The mean value of ANB angle obtained through measurements within this work (Table 1) is similar to that given by Hasund. Before the growth spurt: 3.5 ±2.7; after the finished growth spurt: 2.1 ±2.4. Dibbets [18] measured gains in the length of the mandible Ar-Pg distance. The method proved to have the best reproducibility. From Ricketts work [5] we derived the measurement of Xi-M, i.e. Dist. (the space distally off the first lower molar). The mean change of Dist (Xi-M) was (± 2.90) mm. Forsberg [19] gives the mean size of the lower permanent second molar in males mm (± 0.50), in females mm (± 0.49). Thus we can assume that a major part of the space for the eruption of these teeth has its origin in the resorption of the anterior border of ramus mandibulae. The space allowing inclusion of the lower second molar, which is created during the growth spurt, is proportional to the size of this tooth. The use of mechanics using the space to solve crowding may result in the easier impaction of second molars; and most probably, third molars remain impacted. Conclusion In 80 patients in the growth spurt period 160 lateral cephalograms were analyzed. After the finished growth spurt statistically significant reduction of Gonion angle and angle ANB was proved. redakce@orthodont-cz.cz 33

8 rocïnõâk19 ORTODONCIE stoveâ m spurtu bylo prokaâ zaâ no statisticky vyâ znamneâ zmensï enõâ GonioveÂho uâ hlu aanb. Bylaproka zaâ nastrïedneï silnaâ pozitivnõâ zaâ vislost mezi velikostõâ zmeï ny prostoru distaâ lneï zaprvnõâm staâlyâm dolnõâm molaâ rem azmeï nou vzdaâ lenosti Ar-Pg. Nebylaproka zaâ nastatisticky vyâ znamnaâ zaâ vislost velikosti zmeï ny prostoru distaâ lneï zaprvnõâm staâ lyâ m dolnõâm molaâ rem ani na zmeïneïgouâ hlu ani na zmeïneïuâ hlu ANB. AutorÏi nemajõâ komercï nõâ, vlastnickeâ nebo financï nõâ zaâjmy na produktech nebo spolecï nostech popsanyâch v tomto cïlaâ nku. Literatura/References 1. Prece, J. W.: The incidence of unerupted permanent teeth and related clinical cases. Oral. Surg. 1985, 59, cï. 8, s Franchi, L.; Baccetti, T.; McNamara, J.A.: Mandibular growth as related to cervical vertebral maturation and body height. Amer. J. Orthodont. dentofacial Orthop. 2000, 8, cï. 3, s Baccetti, T.; Franchi, L.; McNamara, J.A.: An improved version of the cervical vertebral maturation (CVM) method for the assessment of mandibular growth. Angle Orthodont. 2002, 72, cï. 4, s Ricketts, R. M.: Cephalometric analysis and synthesis. Angle Orthodont. 1961, 31, cï. 3, s Ricketts, R. M.: A principle of arcial growth of the mandible. Angle Orthodont. 1972, 42, cï. 4, s Moyers, R. E.: Handbook of orthodontics. 4th ed., Chicago: Year Book, Hasund, A.; Segner, D.: Individualizovana kefalometrie. 1. vyd., Praha: HansaDont, Williams, S.: KoncepcÏ naâ ortodoncia, II. Rast a ortopeâ dia. Bratislava: Ing. Juraj HalabrõÂn, Proffit, W. R.; Fields, H. W.: Contemporary orthodontics. 4th ed., St. Louis: Mosby, Bishara, S. E; Staley, R. N.: Mixed-dentition mandibular arch length analysis: a step-by-step approach using the revised Hixon-Oldfather prediction method. Amer. J. Orthodont. 1984, 86, s The medium positive relationship was proved between the amount of change in space distally off the lower first permanent molar and the change in Ar-Pg distance. No statistically significant relationship was proved between the change of space distally off the lower first permanent molar and Gonion or ANB angles. The authors have no comercial, proprietary, or financial interests in the products or companies described in this article. 11. Tanaka, M.; Johnston L.E. The prediction of the size of unerupted canine and premolars in a conteporary orthodontic population. J. Amer. dent. Assoc. 1974, 88, s Richardson, M. E.: The early developmental position of the lower third molar relative to certain jaw dimension. Angle Orthodont. 1970, 40, cï. 3, s Richardson, M. E.: The effect of mandibular first premolar extraction on third molar space. Angle Orthodont. 1989, 59, cï. 4, s Bishara, S. E.: Third molars: A dilemma! Or is it? Amer. J. Orthodont. dentofacial Orthop. 1999, 115, s Zachrisson, B.: Mandibular third molars and late lower arch crowding - the evidence base, World J. Orthodont. 2005, 6, s Sable, D. L.; Woods, M. G.: Growth and treatment changes distal to the mandibular first molar: A lateral cephalometric study. Angle Orthodont. 2004, 74, cï. 3, s RichterovaÂ, L.: Vliv meziaâ lnõâho posunu molaâ ruê navertikaâ lnõâ skeletaâ lnõâ parametry. Odborna praâ ce ke specializacï nõâ zkousï ce z ortodoncie. PlzenÏ Dibbets, J. M.: Mandibular rotation and enlargement, Amer. J. Orthodont. dentofacial Orthop. 1990, 98, cï. 1, s Forsberg, C. M.: Tooth size, spacing, and crowding in relation to eruption or impaction of third molars. Amer. J. Orthodont. dentofacial Orthop. 1988, 94, cï. 1, s MUDr. Bc. ZdeneÏ k Haken Ortodonticke oddeï lenõâ Stomatologicka klinika 1. LF UK KaterÏinska 32, Praha 2 CÏ lenskyâ poplatek pro rok 2010 cï inõâ 1500,- KcÏ nebo 45,- EUR. CÏ lenoveâ v zameï stnaneckeâ m vztahu 800,- KcÏ nebo 25,- EUR. Postgraduanti, duê chodci a zïeny na materïskeâ dovoleneâ 300,- KcÏ nebo 10,- EUR. RegistracÏ nõâ polatek cï inõâ 500,- KcÏ. PrÏedplatne cï asopisu Ortodoncie pro necï leny CÏ OSje 1000,- KcÏ za rok nebo 35,- EUR. U hrada poplatku do , cï.uâ.: /0100, konst. symbol: 0558, variab. symbol: rodneâ cï õâslo. PrÏi nezaplacenõâ prïõâspeï vkuê po dvou põâsemnyâch urgencõâch bude ukoncï eno cï lenstvõâ v CÏ OS redakce@orthodont-cz.cz

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