The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019
RESEARCH ARTICLE

Influence of Lateral Cephalometric Radiographs on Orthodontic Treatment Planning of Class II Patients



Irina Stupar1, Enver Yetkiner2, *, Daniel Wiedemeier3, Thomas Attin4, Rengin Attin5
1 Private Practice, Schulzahnklinik Nord, Hofwiesenstrasse 379, 8050Zürich, Switzerland
2 Faculty of Dentistry, Ege University, Bornova 35100 Izmir, Turkey
3 Department of Statistics, University of Zurich, Zürich, Switzerland
4 Department of Preventive, Periodontology, Cariology University of Zurich, Zürich, Switzerland
5 Department of Orthodontics, Faculty of Dentistry, University of Zurich, Zürich, Switzerland

Abstract

Background:

Lateral Cephalometric Radiographs (LCR) are a common decision-making aid in orthodontic treatment planning and are routinely used in clinical practice. The aim of this present study was to test the null hypothesis that LCR evaluation does not alter specific components of orthodontic treatment planning in Class II patients.

Materials and Methods:

Records of 75 patients, who had been treated at the Department of Orthodontics, Centre of Dental Medicine, University of Zurich comprised the study material. Inclusion criteria were: (1) adolescents between the age of 12-15, (2) permanent dentition with Class II buccal segment relationship (3) absence of craniofacial and dento-alveolar malformations. Fifteen orthodontists from the dental faculties of Istanbul University, Istanbul and Ege University, Izmir filled out Likert-type linear scale questionnaires without knowing that they would repeat the same procedure with and without LCRs at two different time points. Equivalence and clinical relevance were assessed using (%95 CI) Wilcoxon signed rank tests.

Results:

Extraction decision did not differ between groups (p=0.68). Preference of functional appliance use (p=0.006) and inter-maxillary fixed functional appliance (p=0.043) was different among groups.

Conclusion:

LCR evaluation has minor influence on treatment planning procedure of Class II patients. It might be beneficial to consider its prescription not in a routine manner but as a supplementary tool considering possible reduction of radiation exposure.

Keywords: Cephalometric radiographs, Orthodontic treatment, Class II patients, Tooth extraction, Linear Likert-type scale, Dento-alveolar malformations.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 12
First Page: 296
Last Page: 302
Publisher Id: TODENTJ-12-296
DOI: 10.2174/1874210601812010296

Article History:

Received Date: 26/12/2017
Revision Received Date: 28/02/2018
Acceptance Date: 14/3/2018
Electronic publication date: 16/04/2018
Collection year: 2018

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© 2018 Stupar et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Faculty of Dentistry, Ege University, Bornova 35100 Izmir, TURKEY, Tel: +90 (555)4297430, E-mails: enver.yetkiner@gmail.com, eyetkiner@hotmail.com




1. INTRODUCTION

Orthodontic treatment planning is usually based on detailed subjective information obtained from the patient and objective diagnostic records (clinical examination, photograph evaluation, cast analysis and radiographs), which are evaluated by an orthodontist [1Currier GF. Riolo M, Avery JK. Orthodontic exam and diagnosis. Essentials for orthodontic practice 2003; 264-301., 2Proffit WR. Diagnosis & treatment planning. In: Proffit WR, Ed. Contemporary Orthodontics 2012; 147-214.].

Of all diagnostic means, radiographs and their routine prescription remains a critical issue as to proven harms of radiation [3Buchanan IB, Downing A, Stirrups DR. A comparison of the Index of Orthodontic Treatment Need applied clinically and to diagnostic records. Br J Orthod 1994; 21(2): 185-8.[http://dx.doi.org/10.1179/bjo.21.2.185] [PMID: 8043567] , 4Nijkamp PG, Habets LLMH, Aartman IHA, Zentner A. The influence of cephalometrics on orthodontic treatment planning. Eur J Orthod 2008; 30(6): 630-5.[http://dx.doi.org/10.1093/ejo/cjn059] [PMID: 18981169] ]. Especially mentioned is the Lateral Cephalometric Radiography (LCR), which is considered as the “gold standard” at the beginning of an orthodontic treatment [1Currier GF. Riolo M, Avery JK. Orthodontic exam and diagnosis. Essentials for orthodontic practice 2003; 264-301., 5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] , 6Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop 2011; 139(2): e175-81. [PMID:21300228].[http://dx.doi.org/10.1016/j.ajodo.2010.09.021] [PMID: 21300228] ]. An average number of three lateral cephalometric radiographs was reported to be taken during an orthodontic treatment [7Hujoel P, Hollender L, Bollen AM, Young JD, McGee M, Grosso A. Radiographs associated with one episode of orthodontic therapy. J Dent Educ 2006; 70(10): 1061-5. [PMID:17021285].[PMID: 17021285] ].

Even though the contemporary radiographic innovations in dental medicine relatively reduced radiation exposure [8Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562] , 9Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562] ], especially with the help of digital imaging and processing [10Espelid I, Mejàre I, Weerheijm K. EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent 2003; 4(1): 40-8. [PMID:12870988].[PMID: 12870988] ], the harmful effects of radiation are not justified unless it has the potential of changing one’s diagnostic decision [10Espelid I, Mejàre I, Weerheijm K. EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent 2003; 4(1): 40-8. [PMID:12870988].[PMID: 12870988] , 11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] ]. Since the majority of orthodontic patients are children and adolescents, the risk of ionizing radiation accumulation during their lifetime is higher than adults [12Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of ionizing radiation: Assessing what we really know. Proc Natl Acad Sci USA 2003; 100(24): 13761-6. [PMID:14610281].[http://dx.doi.org/10.1073/pnas.2235592100] [PMID: 14610281] ].

LCR is a two-dimensional diagnostic tool for identifying growth patterns, dentofacial proportions and relations between skeletal and dental structures, pathologies and occlusal discrepancies [1Currier GF. Riolo M, Avery JK. Orthodontic exam and diagnosis. Essentials for orthodontic practice 2003; 264-301., 2Proffit WR. Diagnosis & treatment planning. In: Proffit WR, Ed. Contemporary Orthodontics 2012; 147-214.]. It does not offer information about the transverse cranial level.

Since Silling et al [13Silling G, Rauch MA, Pentel L, Garfinkel L, Halberstadt G. The significance of cephalometrics in treatment planning. Angle Orthod 1979; 49(4): 259-62.[PMID: 292348] ] scrutinized the actual need of LCR in orthodontic treatment planning; several other studies asked the same question [4Nijkamp PG, Habets LLMH, Aartman IHA, Zentner A. The influence of cephalometrics on orthodontic treatment planning. Eur J Orthod 2008; 30(6): 630-5.[http://dx.doi.org/10.1093/ejo/cjn059] [PMID: 18981169] -6Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop 2011; 139(2): e175-81. [PMID:21300228].[http://dx.doi.org/10.1016/j.ajodo.2010.09.021] [PMID: 21300228] , 11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] , 14Han UK, Vig KWI, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop 1991; 100(3): 212-9. [PMID:1877545].[http://dx.doi.org/10.1016/0889-5406(91)70058-5] [PMID: 1877545] ]. LCR seemed to have a higher impact on diagnosis than on treatment planning [6Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop 2011; 139(2): e175-81. [PMID:21300228].[http://dx.doi.org/10.1016/j.ajodo.2010.09.021] [PMID: 21300228] ]. On the contrary, it was reported that clinical examination and dental casts might be sufficiently informative to estimate future skeletal development under certain circumstances [6Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop 2011; 139(2): e175-81. [PMID:21300228].[http://dx.doi.org/10.1016/j.ajodo.2010.09.021] [PMID: 21300228] , 15Mok CW, Zhou L, McGrath C, Hägg U, Bendeus M. Digital images as an alternative to orthodontic casts in assessing malocclusion and orthodontic treatment need. Acta Odontol Scand 2007; 65(6): 362-8. [PMID:18071959].[http://dx.doi.org/10.1080/00016350701771850] [PMID: 18071959] , 16Ritschel R, Bechtold TE, Berneburg M. Effect of cephalograms on decisions for early orthodontic treatment. Angle Orthod 2013; 83(6): 1059-65. [PMCID: PMC3932141].[http://dx.doi.org/10.2319/021113-124.1] [PMID: 23724806] ].

Tooth extraction, one of the most invasive interventions in orthodontics to generate extra space, is usually supported by findings from the LCR analyses deviating from average norms [5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] , 11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] ]. Moreover, it was reported that orthodontists might have personal tendencies for extraction or non-extraction therapies [5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] , 9Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562] ], making the decision inter alia through LCR.

These observations raise the question, if the presence of LCR is influential on orthodontic treatment decisions, especially on irreversible decisions such as extractions.

Therefore, the aim of this study was to investigate the influence of LCR on orthodontic treatment planning in Class II patients at two points of time (T1 & T2) with or without LCR. The null hypothesis was that the use of LCR does not influence the treatment planning stage of Class II patients.

2. MATERIALS AND METHODS

2.1. Study Design and Subjects

Five orthodontists from Ege University, Izmir and ten orthodontists from Istanbul University participated the study as evaluators. They were not informed about the aim or subject of the study (Fig. 1). Complete pre-treatment diagnostic files of seventy-five Class II patients from Department of Orthodontics and Pedodontics, University of Zurich archive were collected. These subjects fulfilled the following criteria: (1) permanent dentition (2) absence of craniofacial and dento-alveolar malformations, (3) Class II buccal segment relationship.

Files contained dental casts including cast analysis results, extra-oral photographs, panoramic radiographs and lateral cephalograms with associated tracings. Patient files were anonymized and numbered. Pictures (en-face, profile & ¾ profile) were masked. All data were digitally presented and there was no time limit for evaluating the cases and decision-making. The principal treatment objective was to accomplish a healthy functional occlusion with soft tissue harmony [11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] ]. There was no restriction given in materials or financial conditions for treatment planning [11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] ].

Half of the patient files did have LCR with the analysis, the other half were without LCRs. After four weeks (T2) the procedure was repeated with the same set of patient records excluding the LCR analysis of the patients, who had at T1 the complete radiographic analysis (LCR), and vice versa (Fig. 1).

The questionnaire was designed as a linear Likert-type scale corresponding to a previous study [9Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562] ]. With regard to the question of extraction or non-extraction, following questions had to be answered for each case: (1) definitely extraction, (2) extraction, (3) borderline, may or may not extract, (4) non-extraction, (5) definitely non-extraction.

Additionally, other ten therapy possibilities were also evaluated: (1) removable appliance, restricted to one jaw, (2) lower lingual arch and/or transpalatal arch, (3) headgear or skeletal anchorage, (4) functional appliance, (5) combinations of multiple choices 3 and 1, 2 or 3, (6) 3. Or 4. followed by fixed appliance, (7) only fixed appliance, (8) intermaxillary fixed functional, (9) extraction, (10) surgical treatment, (11) retention: a. fixed retention, b. removable retention, c. functional retainer.

Fig. (1)
Flowchart of the study design.


The discrepancy of questions at T1 and T2 were observed and calculated (T2-T1). The bigger the discrepancy, the more likely the answers differed from each other. Those differences were visually displayed in Fig. (2).

Fig. (2)
Graphical overview. Every single point illustrates the discrepancy of answers of each orthodontist to each question (T2-T1). For example: The answer for question 1 at T1 was definitely yes equal to 1, but at T2 it was definitely no, which corresponds to 5 – from this it follows that the discrepancy is 4 (T2-T1), which is marked as a single point at the y-axis.


2.2. Statistical Analysis

The ordinal scale data was encoded in Excel and statistically analyzed with the software R and plots were done with the ggplot 2 package.

Due to the cross-over study design and the ordinal scale of the target variables, a Wilcoxon signed-rank-test was used to determine significant differences between the treatment (with LRC) and control (without LRC) groups.

Equivalence and clinical relevance were assessed by considering the 95%-Confidence Interval (CI) of the Wilcoxon signed rank tests. Significant results were considered at p < 0.05.

3. RESULTS

Figs. (2 and 3) show a graphical overview regarding eleven analyzed choices, which were tested on respectively significant differences. Exclusion of LCR did not make a difference in any of the questions.

Fig. (3)
Difference in scores with / without X-ray. All examined questions are listed in the x-axis from 1 to 11c. The y-axis represents the percentage of differences in answering each question. It is visible that over 50% of answers did not differ at T1 and T2.


Decision of extraction vs. non-extraction therapy was indifferent (p=0.68). The power of 0.08 was low, supporting the assumption that there was no difference between control and orthodontic decision making with LCR.

Every single point illustrates the discrepancy of answers of each orthodontist to each question (T2-T1). For example: The answer for question 1 at T1 was definitely yes equal to 1, but at T2 it was definitely no, which corresponds to 5, from this it follows that the discrepancy is 4 (T2-T1), which is marked as a single point at the y-axis.

In Fig. (2) the discrepancy per question is shown. 0 in the y-axis stands for no differences between with or without LCR. Points are slightly jittered in order to improve the visual assessment. There is no asymmetrical pattern recognizable, in other words the deviation is balanced on both sides without any tendency. Every point means one discrepancy of one orthodontist. The bigger the difference, the more likely the answers differed from each other (T2-T1). All differences were non significant (p>0.05) except for question four, concerning functional appliance (p=0.006) and question eight, intermaxillary fixed functional appliance (p=0.043).

The y-axis represents the percentage of differences in answering each question. It is visible that over 50% of answers did not differ at T1 and T2.

4. DISCUSSION

In this study, the influence of LCR on different treatment decisions in Class II patients was tested. No evidence of a difference between treatment planning with or without LCR was found. Therefore, the null hypothesis that the cephalometric evaluation of Class II patients would not affect the treatment planning stage cannot be rejected.

The number of evaluators has a potential for possible bias, however, the focus was on verifying a difference between specific treatment decisions with/without LCR, neglecting possible individual factors of each orthodontist. Therefore, it can be assumed that 15 evaluators from two different centers might resemble an average population of orthodontists. The patient files were presented digitally and this might be an influencing factor on the orthodontists’ decisions since they are used to evaluating patients physically in real life and this might have affected the reliability of data. Similarly, dental casts were on photographs and not physically presented, which might have impeded the evaluation. However, it was shown previously that two-dimensional digital images can be used as an alternative to study casts to examine the actual need of an orthodontic treatment [15Mok CW, Zhou L, McGrath C, Hägg U, Bendeus M. Digital images as an alternative to orthodontic casts in assessing malocclusion and orthodontic treatment need. Acta Odontol Scand 2007; 65(6): 362-8. [PMID:18071959].[http://dx.doi.org/10.1080/00016350701771850] [PMID: 18071959] ] and this was the only way of presenting the patient files to visualize the patient in professional platforms and discussions [11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] ].

Exclusion of the LCR did not influence the orthodontic treatment decision of extraction, which is rather an irreversible decision. This recognition corresponds with previous studies [6Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop 2011; 139(2): e175-81. [PMID:21300228].[http://dx.doi.org/10.1016/j.ajodo.2010.09.021] [PMID: 21300228] , 11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] , 14Han UK, Vig KWI, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop 1991; 100(3): 212-9. [PMID:1877545].[http://dx.doi.org/10.1016/0889-5406(91)70058-5] [PMID: 1877545] , 16Ritschel R, Bechtold TE, Berneburg M. Effect of cephalograms on decisions for early orthodontic treatment. Angle Orthod 2013; 83(6): 1059-65. [PMCID: PMC3932141].[http://dx.doi.org/10.2319/021113-124.1] [PMID: 23724806] ]. The contribution of the LCR to orthodontic decision making, as one of the essential orthodontic diagnostic materials might be questionable [5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] , 6Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop 2011; 139(2): e175-81. [PMID:21300228].[http://dx.doi.org/10.1016/j.ajodo.2010.09.021] [PMID: 21300228] ]. LCR was considered as a gold standard in previous years since the main aim of orthodontic treatment was to treat the patient to cephalometric norms. With the paradigm shift of orthodontic aim from cephalometric norms to treating the face to harmonious soft and hard tissue relations, contribution of this tool gradually became questionable. Clinical evaluation of individual static and dynamic components started to become more decisive rather than average cephalometric values. Therefore, additional use of LCR remains controversial due to the individual character of each orthodontic treatment plan [13Silling G, Rauch MA, Pentel L, Garfinkel L, Halberstadt G. The significance of cephalometrics in treatment planning. Angle Orthod 1979; 49(4): 259-62.[PMID: 292348] -16Ritschel R, Bechtold TE, Berneburg M. Effect of cephalograms on decisions for early orthodontic treatment. Angle Orthod 2013; 83(6): 1059-65. [PMCID: PMC3932141].[http://dx.doi.org/10.2319/021113-124.1] [PMID: 23724806] ]. Considering the routine clinical inspection and the following evaluation of the diagnostic materials consisting of dental casts, photographs and panoramic x-rays, LCR might not be essential unless providing supplementary information in certain cases. Thus, routine prescription may be unnecessary exposure to radiation. Previously, it has been suggested that information set of radiography at initial treatment and obtain initial information out of study casts alone [15Mok CW, Zhou L, McGrath C, Hägg U, Bendeus M. Digital images as an alternative to orthodontic casts in assessing malocclusion and orthodontic treatment need. Acta Odontol Scand 2007; 65(6): 362-8. [PMID:18071959].[http://dx.doi.org/10.1080/00016350701771850] [PMID: 18071959] ], would definitely reduce unnecessary radiation doses and even increase the benefit out of LCR [17Isaacson KG, Thom A. Guidelines for the use of radiographs in clinical orthodontics 2001.]. The good agreement between stages of orthodontic therapy means, either on clinical examination or on the base of study casts was already described [14Han UK, Vig KWI, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop 1991; 100(3): 212-9. [PMID:1877545].[http://dx.doi.org/10.1016/0889-5406(91)70058-5] [PMID: 1877545] , 16Ritschel R, Bechtold TE, Berneburg M. Effect of cephalograms on decisions for early orthodontic treatment. Angle Orthod 2013; 83(6): 1059-65. [PMCID: PMC3932141].[http://dx.doi.org/10.2319/021113-124.1] [PMID: 23724806] ].

The shortcomings of traditional radiographic imaging are another subject to discuss in terms of justification of ionizing radiation. Even though the trend of digital radiography could reduce the amount of ionizing radiation, the biological risk for growing individuals, as the biggest segment of orthodontic patient population, remains [8Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562] -10Espelid I, Mejàre I, Weerheijm K. EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent 2003; 4(1): 40-8. [PMID:12870988].[PMID: 12870988] ]. The danger of low-dosage radiation in children is still fully not clarified [9Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562] , 10Espelid I, Mejàre I, Weerheijm K. EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent 2003; 4(1): 40-8. [PMID:12870988].[PMID: 12870988] ]. As it is anticipated, each radiographic image has its own sources of drawbacks like magnification-distortion or positioning errors, which may increase the amount of ionization [1Currier GF. Riolo M, Avery JK. Orthodontic exam and diagnosis. Essentials for orthodontic practice 2003; 264-301., 11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] , 18Macri V, Athanasiou AE. Sources of error in lateral cephalometry.Orthodontic Cephalometry 1995; 125-40.].

A recent study [11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] ] reported a possible tendency to extraction with/without LCR in the level of experience of the individual orthodontist according to dichotomized results. The inconsistency in the results was interpreted as a disparity in field experience [11Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887] ]. This difference in years of experience in correlation to the use of cephalographs might be an objective for a further study and would answer the question, whether the presence or non-presence of LCR is differently influencing experienced and inexperienced clinicians.

LCR is used routinely for supporting the orthodontic decision to extract or non-extract, an irreversible and invasive treatment [4Nijkamp PG, Habets LLMH, Aartman IHA, Zentner A. The influence of cephalometrics on orthodontic treatment planning. Eur J Orthod 2008; 30(6): 630-5.[http://dx.doi.org/10.1093/ejo/cjn059] [PMID: 18981169] , 5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] , 19Weintraub JA, Vig PS, Brown C, Kowalski CJ. The prevalence of orthodontic extractions. Am J Orthod Dentofacial Orthop 1989; 96(6): 462-6. [PMID:2589256].[http://dx.doi.org/10.1016/0889-5406(89)90112-1] [PMID: 2589256] -21Vaden JL. MS, Kiser HHE. Straight talk about extraction and nonextraction: A differential dignostic decision. Am J Orthod Dentofacial Orthop 1996; 109: 393-402. [PMID:8638587].[http://dx.doi.org/10.1016/S0889-5406(96)70127-0] [PMID: 8638581] ]. Teeth extraction does not only influence the facial appearance regarding soft tissues and dental arch length dimensions [2Proffit WR. Diagnosis & treatment planning. In: Proffit WR, Ed. Contemporary Orthodontics 2012; 147-214., 5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] ], but also presents a psychological impact on the patient. Baumrind and coworkers [5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] ] stated regarding the extraction decision, orthodontists were even more focused on appearance related factors, which were visible on dental casts and facial photographs, than on radiography [5Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581] ]. Even if some may criticize the precision of analyzing skeletal orthodontic issues without radiographic help, it was noted that clinicians could simply distinguish a Class I profile when compared to Class II and Class III by only clinical examination [22Cochrane SM, Cunningham SJ, Hunt NP. A comparison of the perception of facial profile by the general public and 3 groups of clinicians. Int J Adult Orthodon Orthognath Surg 1999; 14(4): 291-5. [PMID:10895644].[PMID: 10895644] ].

In the present study, the extraction of third molars was excluded, which might apply as a disadvantage, because of the possible participation in a treatment planning regarding the posterior dental arch. The exclusion of third molars into decision prevented potential positive results of extraction. One other limitation was the limited number of evaluators and centers. Information gathered from a higher number of orthodontists from a larger group of centers would represent the orthodontic community more accurately.

CONCLUSION

The presence of LCR does not influence the orthodontic decision to extract or non-extract. Thus, the need of LCR in Class II patients should be reconsidered, additionally to prevent unnecessary ionizing radiation and reassess the routinely use in orthodontics.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study was approved by the Ethics in Research Committee of University of Ege, Izmir, Turkey (16-1.1/14).

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2008.

CONSENT FOR PUBLICATION

Written informed consent was obtained from the patient for publication of this study.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Currier GF. Riolo M, Avery JK. Orthodontic exam and diagnosis. Essentials for orthodontic practice 2003; 264-301.
[2] Proffit WR. Diagnosis & treatment planning. In: Proffit WR, Ed. Contemporary Orthodontics 2012; 147-214.
[3] Buchanan IB, Downing A, Stirrups DR. A comparison of the Index of Orthodontic Treatment Need applied clinically and to diagnostic records. Br J Orthod 1994; 21(2): 185-8.[http://dx.doi.org/10.1179/bjo.21.2.185] [PMID: 8043567]
[4] Nijkamp PG, Habets LLMH, Aartman IHA, Zentner A. The influence of cephalometrics on orthodontic treatment planning. Eur J Orthod 2008; 30(6): 630-5.[http://dx.doi.org/10.1093/ejo/cjn059] [PMID: 18981169]
[5] Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians’ stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996; 109(4): 393-402. [PMID: 8638581].[http://dx.doi.org/10.1016/S0889-5406(96)70121-X] [PMID: 8638581]
[6] Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop 2011; 139(2): e175-81. [PMID:21300228].[http://dx.doi.org/10.1016/j.ajodo.2010.09.021] [PMID: 21300228]
[7] Hujoel P, Hollender L, Bollen AM, Young JD, McGee M, Grosso A. Radiographs associated with one episode of orthodontic therapy. J Dent Educ 2006; 70(10): 1061-5. [PMID:17021285].[PMID: 17021285]
[8] Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: Estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562]
[9] Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363(9406): 345-51. [PMID:15070562].[http://dx.doi.org/10.1016/S0140-6736(04)15433-0] [PMID: 15070562]
[10] Espelid I, Mejàre I, Weerheijm K. EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent 2003; 4(1): 40-8. [PMID:12870988].[PMID: 12870988]
[11] Dinçer B, Yetkiner E, Aras I, Attin T, Attin R. Influence of lateral cephalometric radiographs on extraction decision in skeletal class I patients. Head Face Med 2013; 9: 36. [PMID:24304887].[http://dx.doi.org/10.1186/1746-160X-9-36] [PMID: 24304887]
[12] Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of ionizing radiation: Assessing what we really know. Proc Natl Acad Sci USA 2003; 100(24): 13761-6. [PMID:14610281].[http://dx.doi.org/10.1073/pnas.2235592100] [PMID: 14610281]
[13] Silling G, Rauch MA, Pentel L, Garfinkel L, Halberstadt G. The significance of cephalometrics in treatment planning. Angle Orthod 1979; 49(4): 259-62.[PMID: 292348]
[14] Han UK, Vig KWI, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop 1991; 100(3): 212-9. [PMID:1877545].[http://dx.doi.org/10.1016/0889-5406(91)70058-5] [PMID: 1877545]
[15] Mok CW, Zhou L, McGrath C, Hägg U, Bendeus M. Digital images as an alternative to orthodontic casts in assessing malocclusion and orthodontic treatment need. Acta Odontol Scand 2007; 65(6): 362-8. [PMID:18071959].[http://dx.doi.org/10.1080/00016350701771850] [PMID: 18071959]
[16] Ritschel R, Bechtold TE, Berneburg M. Effect of cephalograms on decisions for early orthodontic treatment. Angle Orthod 2013; 83(6): 1059-65. [PMCID: PMC3932141].[http://dx.doi.org/10.2319/021113-124.1] [PMID: 23724806]
[17] Isaacson KG, Thom A. Guidelines for the use of radiographs in clinical orthodontics 2001.
[18] Macri V, Athanasiou AE. Sources of error in lateral cephalometry.Orthodontic Cephalometry 1995; 125-40.
[19] Weintraub JA, Vig PS, Brown C, Kowalski CJ. The prevalence of orthodontic extractions. Am J Orthod Dentofacial Orthop 1989; 96(6): 462-6. [PMID:2589256].[http://dx.doi.org/10.1016/0889-5406(89)90112-1] [PMID: 2589256]
[20] Keim RG, Gottlieb EL, Vogels DS III, Vogels PB. 2014 JCO study of orthodontic diagnosis and treatment procedures, Part 1: Results and trends. J Clin Orthod 2014; 48(10): 607-30. [PMID:25416338].[PMID: 25416338]
[21] Vaden JL. MS, Kiser HHE. Straight talk about extraction and nonextraction: A differential dignostic decision. Am J Orthod Dentofacial Orthop 1996; 109: 393-402. [PMID:8638587].[http://dx.doi.org/10.1016/S0889-5406(96)70127-0] [PMID: 8638581]
[22] Cochrane SM, Cunningham SJ, Hunt NP. A comparison of the perception of facial profile by the general public and 3 groups of clinicians. Int J Adult Orthodon Orthognath Surg 1999; 14(4): 291-5. [PMID:10895644].[PMID: 10895644]

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