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18 Dental, Occlusal, andFunctional Evaluation ofPatients

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Table 18.1 Validity of standard and exceptional caries detection tests

Caries detection test Sensitivity Specicity Source Visual examination 0.70 0.41 [41] Conventional bitewing radiograph (D-speed, invivo) 0.65 0.58 [41] Conventional bitewing radiograph (E-speed, invivo) 0.80 0.94 [41] Bitewing radiograph+computerized decision aid (in vitro) 0.67 0.83 [53] FOTI (in vitro) 0.97 0.50 [41] DIFOTI 0.97 0.50 [41] LF (DIAGNOdent 2095, KaVo, Biberach, Germany; invivo) 0.88 0.71 [41] LF (DIAGNOdent 2095, invitro) 0.75 0.76 [41] LF (DIAGNOdent pen 2190, invitro) 0.78 0.77 [41] QLF (proximal, |∆Fmax| cutoff=5.95, invivo) OCT (coronal plane, invitro) 0.81 1.00 [55]

0.74 0.73 [54]

243

light because enamel is very translucent to these wavelengths. The emitted, frequency-sweep laser light is coupled to the object and a reference surface. The interference pattern is used to calculate an image. First results are promising as OCT showed better performance in detecting very early lesions than laser uorescence and QLF [52].

Although visual inspection, radiographic examination, and tactile test are available in everyday practice, inexpensive, reliable, and easily performed, the new techniques may improve caries diagnostics in future and be of special value in patients with craniofacial malformations.

Validity expressed in sensitivity and specicity values of standard and exceptional caries detection tests is listed in Table18.1.

Dental Pulp andPeriapical Status

Pulp sensitivity tests can be performed simply by applying a thermal or electrical stimulus to the cervical area [56–59]. However, test results do not necessarily correlate with histologic ndings as a gold standard and are a questionable basis for further therapy in the case of obliteration without infection [60–62]. In patients who have undergone oral surgery, particularly mandibular orthognathic operations, tooth pulp sensitivity to thermal or electrical stimuli may be

reduced even in the absence of pulp tissue damage [63–65]. A reliable method for measuring dental pulp vitality is laser Doppler owmetry. A laser beam is directed at the tooth surface and passes through enamel and dentin to the pulp. There, circulating blood cells reect the laser beam, and cell movement alters the reected signal through the Doppler effect. Sensitivity and specicity of this test are reported to be high (0.82–100% sensitivity and 100% specicity) [66]. Dental pulp oximetry shows similar validity. However, pulp blood supply may be reduced without compromising tooth vitality, e.g., on the affected side of a cleft palate [67]. As a conclusion, in patients suffering from craniofacial malformations, particularly after orthognathic surgery, pulp sensitivity tests based on thermal or electrical stimuli should be interpreted with caution. Comparison with the condition of the clinical crown and radiological ndings should be used before invasive endodontic procedures are initiated.

If toxins from the dental pulp inltrate the periapical periodontal ligament, the affected tooth might be sensitive to pressure or touching. This condition can be examined by a percussion test [68].

Sensitivity and specicity values of standard and exceptional tests to evaluate pulp sensibility and periapical inammation are listed in Table18.2.

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Table 18.2 Validity of standard and exceptional pulp sensibility and periapical status tests

Pulp sensibility and periapical status test Sensitivity Specicity Source

Cold stimulus 0.83 0.93 [18] Cold stimulus 0.916 0.896 [17] Warm stimulus 0.86 0.41 [18] Electric stimulus 0.72 0.93 [18] Electric stimulus 0.84 0.74 [17] Laser Doppler owmetry Pulse oximetry 0.81 0.95 [66] Periapical status Pain on tooth

percussion

0.82–1.00 1.00 [66]

0.72 0.41 [68]

Periodontal Examination

The basic examination procedures for periodontal disease are probing the depth of the periodontal sulcus, visual examination of bleeding on probing, and radiographic examination of attachment loss. Probing depth correlates to the further progression of periodontal disease and therefore is a valid diagnostic aid [69]. However, there is only limited knowledge about the periodontal health of patients with craniofacial malformations. In syndromic craniosynostoses, tooth crowding, hypoplasia of the upper jaw, and gingival hyperplasia are suspected to contribute to plaque accumulation, and mouth breathing is also a factor discussed in this context [70]. Treatment of mandibular underdevelopment by distraction osteogenesis, e.g., in patients with hemifacial microsomia, might be a risk factor for juvenile paradental cysts, which have to be distinguished from lateral radicular inammatory cysts [71].

A common but invasive and time-consuming method to assess the periodontal health status is measuring the periodontal pocket depth by probing. In combination, bleeding on probing (BOP) and presence of plaque and calculus or defective crown margins can be assessed. As a full examination of these parameters, e.g., in the Community Periodontal Index for Treatment Need (CPITN), takes a lot of time and is not comfortable to the patient, reduced screening procedures were proposed, e.g., the partial CPITN using only ten

index teeth with limited inuence on sensitivity and specicity values (0.58 and 0.81 for full CPITN and 0.50 and 0.87 for partial CPITN, respectively) [72]. The CPITN was modied to the Periodontal Screening and Recording Index (PSR) to reduce examination time [73].

With the Periotest® device (Gulden, Modautal, Germany), periodontal reaction to an impulse induced to the crown surface can be measured. Correlation with bone loss has been reported to be strong [74].

As gingival bleeding is a frequent symptom of periodontitis, saliva hemoglobin levels have been evaluated for their suitability to detect this disease without probing the pocket depth. In combination with a self-report questionnaire, a sensitivity of 0.7 and specicity >0.75 have been reported [75]. A simple, also noninvasive screening method for periodontitis using saliva hemoglobin and saliva lactate dehydrogenase levels in combination was introduced by Nomura [76]. Using both values has been reported to have a positive predictive value of 91.7%. Other periodontal diagnostic tests, e.g., for microbiome [77–79] or interleukin-1 genotype [77, 78, 80,

81], should be interpreted with care in general

[82] and have not been evaluated for their application in craniofacial malformation patients yet. An inuence of the underlying genetic variation on test results cannot be ruled out at present; for example, it has been reported that Apert patients exhibit a higher interleukin-1 receptor antagonist level [83] and altered extracellular matrix proteins [84].

Dental Misalignment, Temporomandibular Disorders, andMalocclusion

Pronounced underdevelopments of the midface (especially in conjunction with a cleft) or the mandible in patients with craniofacial malformations almost necessarily lead to misalignment and malocclusion of the dental arches. Especially malformations of the temporomandibular joints (up to complete aplasia of the condyle) lead to a position and function deviating from the physio-

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logic situation. In these cases, temporomandibular joint dysfunction and malocclusion are frequently present. However, craniofacial malformations might or might not be associated with (painful) temporomandibular disorders (TMDs). Temporomandibular disorders are dened as “conditions producing abnormal, incomplete, or impaired function of the temporomandibular joint(s) and/or the muscles of mastication” [85].

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) have been developed from the former Research Diagnostic Criteria and proven to be a reliable diagnostic tool [86]. The screening tool consists of two axes. With axis I, pain history (within the preceding 30days; masseter and temporal muscles, other orofacial muscles, and headache, with or without referral) and physical function and condition of the temporomandibular joints are assessed. Axis II refers to the psychosocial status. DC/TMD protocol is evidence based, valid, and applicable in clinical and research settings. However, not every single item might be applicable in patients with craniofacial malformations; for example, in complete condylar aplasia, anterior disc displacement is probably hard to dene. In patients with craniofacial malformations, a lot of diagnostic information is already available and should be evaluated with respect to TMD.As De Boever etal. (2000) stated: “The diagnosis should be based on sound judgement of a careful medical and dental history, detailed clinical examination, and some optional modalities, such as radiographs of the jaws and imaging of the TMJs” [87].

Frequently used parameters of misalignment and malocclusion in orthodontic and orthognathic examination are overbite, overjet, crossbite, dental crowding, congenital missing teeth, and midline deviation [88].

Kobayashi etal. found anterior open bite (i.e., overbite <−4mm) in 6 out of 7 cases of Apert, and 2 out of 12 cases in Crouzon syndrome, respectively. Posterior crossbite was found in every subject of both craniofacial malformations. Severe dental crowding (i.e., arch length discrepancy >10mm) in the upper jaw was present in 6 of 7 Apert syndrome and 2 of 12 Crouzon syndrome patients. The corresponding numbers of

the mandibular arch are 3 out of 7 and 1 out of 12, respectively. Due to sagittal underdevelopment of the midface, patients had an average overjet of

−8.2mm in case of Apert and −5.3mm in case of Crouzon syndrome [6].

Malformations from the craniofacial microsomia complex arise from the rst and second pharyngeal arches, and underdevelopment of the mandible is a typical consequence [89, 90]. This frequently leads to an Angle class II malocclusion [32]. Again, anterior open bite is a frequent condition, caused by a shortened posterior vertical height of the mandible [91].

Thorough orthodontic and cephalometric examination is essential for successful treatment outcome, and regular follow-up examinations are mandatory as long-term relapse is possible [92].

Due to the severity of malocclusion, occlusal adjustment is achieved by craniofacial and orthognathic surgery, orthodontic treatment, and, nally, other measures like selective occlusal substance removal or augmentation, e.g., by bonded composite restorations, veneers, crowns, and, in some cases, occlusal splints or xed or removable partial dentures.

During these treatment procedures, instrumental centric relation records might be advantageous for treatment planning and to evaluate the treatment outcome. However, common facebows might not always be suitable for craniofacial malformation patients. For example, facebows using earplugs for xation like the ARCUS/ARCUSevo® (KaVo, Biberach, Germany), Artex® (Amann Girrbach, Koblach, Austria), DENAR® Slidematic® (Whip Mix, Louisville, KY, USA), and SAM® AXIOQuick III® (SAM Praezisionstechnik, Gauting, Germany) have one drawback in common: they need both external ear canals in their physiological position to be properly xed. In craniofacial malformations, one or both external ear canals might not be present or be ectopic. However, facebows still might be helpful: In reversal of its intended purpose, the use of a facebow to support the positioning of bilateral auricular prostheses was demonstrated using the example of a patient with Crouzon syndrome [93]. Facebows and articulators also

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might not be adjustable to an individual position of the occlusal plane far away from the average. In cases with condylar aplasia, mandibular movements may become irregular and simulation with a mechanical articulator impossible. With the possibility of movement tracking using intraoral scanners, mandibular movements can be simulated digitally without mechanical limitations [94].

In the future, a newly developed technique could make it possible to draw the hinge axis and sagittal condylar pathway on the patient’s skin and integrate them with the three-dimensional patient data using a face scan [95].

Conclusions

Patients with craniofacial malformations require particularly careful, regular dental examinations. New technologies in caries detection and periodontitis diagnosis as well as intraoral scanning may facilitate the examination procedure and registration of irregular mandibular movements. However, the underlying disease and consequences of orthognathic surgery may have an inuence on some of the test results.

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Stereoscopic Imaging

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ofCraniofacial Malformations

ChristophRunte, MarkusDeki, andDieterDirksen

Introduction

Stereoscopic vision allows spatial recognition of three-dimensional objects. Spatial perception of anatomical structures is a fundamental prerequisite especially for performing surgical interventions. Unsurprisingly, surgeons show high-level competence in stereoacuity [1]. In a recent metaanalysis, Bogomolova et al. [2] showed an enhanced learning effect for anatomical content, if stereoscopic imaging was used in an interactive environment. “Interaction” included the ability to rotate the object. Rotating the object means adding different perspectives, which means that in this kind of interaction, other important clues for spatial recognition were presented along with stereoscopic viewing. However, comparing interactive stereoscopic 3D models to interactive monoscopic 3D models still showed a positive effect of stereoscopic presentation [2].

Spatial Perception

linear perspective, shadow position, illumination by close light sources, color saturation and brightness, and stereopsis. Stereoscopic viewing is most effective in spatial recognition of close objects. Theoretically, triangulation allows a very precise determination of distance. However, human stereoscopic perception is subject to two systematic errors: visuospatial compression and depth underconstancy [3]. “Visuospatial compression” refers to the fact that the distance of near objects is overestimated and that of far objects is underestimated. “Depth underconstancy” means that objects appear atter and atter with increasing distance from the viewer. At very close distances, parallax angle to background objects gets too large, and at greater distances, parallax is too small to perceive distance. Spatial perception therefore should be regarded as a process based on different sensations, with stereopsis being one of the most important. It was shown that even if all other depth cues were eliminated, binocular depth perception of visual stimuli is still possible [4].

If we are looking at a three-dimensional scenery, we can estimate the relative distance of objects by several clues, e.g., perceived size of the object, movements, partial occlusion by other objects,

C. Runte (*) · M. Dekiff · D. Dirksen Department of Prosthodontics, University of Muenster, Muenster, Germany e-mail: crunte@uni-muenster.de

https://doi.org/10.1007/978-3-031-28069-6_19

Production andAlignment ofStereoscopic Images

Stereoscopic images of craniofacial malformations can be obtained from already available 3D data (e.g., from CT scans, MRI, or facial surface scans) or taken by stereoscopic camera systems.

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C. Runte et al.

With existing 3D data, common 3D programs can be used to create a pair of images from two perspectives shifted in parallel and to save them using the export or screenshot function of the program. In doing so, a vertical offset or rotation of the virtual camera’s position must be avoided. With programs such as “StereoPhoto Maker” (http://stereo.jpn.org/eng/stphmkr/index.html), correct adjustment of the image pairs and export to various formats are possible.

Stereo photographic images of the facial surface will probably be less helpful in examination and diagnosis, as they only show what can also be seen. In stereoscopic photographs, interactive rotation of the images is not possible, but nevertheless they might be helpful in education and easier at hand in comparison to a 3D surface scan.

Some equipment for stereo photography are depicted in Fig.19.1. Digital stereoscopic cameras such as the FinePix Real 3D W1 and W3 (Fujilm, Tokyo, Japan) have been available; however, in most cases, production has ceased. They usually had a xed stereoscopic baseline (distance between the two camera lenses) similar to human eye distance. However, such a stereoscopic baseline should not be used for close-up images, as it would lead to a large stereoscopic disparity. The closest and farthest objects in a stereoscopic image pair should have a parallax angle below 70′ [1, 5]. As a simple rule of thumb, when adjusting an image pair to the far point, the deviation of the left and right far point can be set to 1/30 to 1/40 of the picture width. Objects at the distance of the stereo window (= the frame around each image of the

Fig. 19.1 Digital stereo camera FinePix Real 3D W3® (upper left); digital SLR camera (Nikon D100, Nikon Corp., Tokyo, Japan) with stereoscopic macro lens (De Wijs apparatenbouw, Houten, the Netherlands; upper right); digital SLR camera (Nikon D100) with medical Nikkor Makro Lens (Nikon Corp., Tokyo, Japan), mounted on a Manfrotto micro-positioning sliding plate

(Manfrotto, Cassola, Italy) and with additional Traumieger twin ashes (Traumieger Fotographics, Wedel, Germany; lower left); and light eld camera Lytro Illum light eld camera (lower right) with an LED ring light (Walimex universal ring light, Studioexpress GmbH, Wiernsheim, Germany)

19 Stereoscopic Imaging ofCraniofacial Malformations

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pair that is perceived as a window at a certain distance through which the image pair is seen) have no stereoscopic disparity in the adjusted image pair. The closest point should usually not be located in front of the stereo window. If a close object is cut by the frame of the stereo window, it will be perceived as partially occluded by the frame. This would be contradictory to a perceived closer distance to the observer. Only elements in the picture center might be located closer to the observer than the stereo window [6].

Immobile objects may be photographed from two perspectives one after the other, which allows also to use small stereoscopic baselines, e.g., by a positioning sliding plate for the camera. However, in this case, external, immobile ashlights or diffusors should be used in order to avoid different shadows in the stereoscopic images.

Light eld cameras, especially the Lytro Illum camera (Lytro Inc., Mountain View, USA), also offer the possibility to produce stereoscopic image pairs. Since the possible stereoscopic baseline is very small, close-up recordings are possible. The camera is easy to use, but the resulting images have a comparatively low resolution, and depth information is of limited precision. Sales of the camera were discontinued in 2018.

Presentation ofStereoscopic Images

The need for special equipment for comfortable stereoscopic viewing seems to be the main obstacle to its application. Therefore, 3D technology was mainly used by few enthusiasts for a long time. When from around the year 2000 onwards, the equipment in the cinemas of large operator chains was upgraded to digital technology; this was an opportunity to re-establish 3D technology in cinemas at the same time (after earlier, rather short-lived approaches and specialized theatres such as IMAX 3D [7]). In 2009, several 3D movies, e.g., “Avatar” by James Cameron (USA,

2009), were released [8]. As a result, the demand for stereoscopic equipment in the private sector also increased and stereoscopic devices, for example stereoscopic monitors with shutter glasses and autostereoscopic displays for stereo cameras, became available.

For interactive stereoscopic display of 3D data, powerful computers and graphic cards as well as special software are necessary due to the high data volume and calculation time (Fig.19.2).

Noninteractive presentation is possible by using image pairs instead of 3D data. Possible

Fig. 19.2 Interactive presentation software DView® (unpublished, by Prof. Dr. D.Dirksen, Münster, Germany). Display is set to anaglyph; shutter and lenticular displays are also possible. The user can interactively rotate and scale the 3D object (volume tomography of an oculo-

auriculo- vertebral dysplasia patient, data used with kind permission of Prof. Dr. Dr. U.Meyer). With the clip box activated, sections in any directions can be made by shifting the spherical marks. Data format was .stl

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