Online ISSN : 2249-4618

Print ISSN : 0975-5888

DOI : 10.17406/GJMRA

Update
of
Cariology
Terminology Surgical
Treatment
Alternatives

Tool
for
Identifying
Growth
Pattern Analyzing
the
Intraoperative
Parameters

VOLUME
22









ISSUE
2









VERSION
1.0
Global Journal of Medical Research: J
Dentistry & Otolaryngology
Global Journal of Medical Research: J
Dentistry & Otolaryngology
Volume 2 2 Issue 2 (Ver. 1.0)

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 Editorial Board
Global Journal of Medical Research

Dr. Apostolos Ch. Zarros Dr. William Chi-shing Cho

DM, Degree (Ptychio) holder in Medicine, Ph.D.,

National and Kapodistrian University of Athens Department of Clinical Oncology
MRes, Master of Research in Molecular Functions in Queen Elizabeth Hospital
Disease, University of Glasgow FRNS, Fellow, Royal Hong Kong
Numismatic Society Member, European Society for
Neurochemistry Member, Royal Institute of Philosophy
Scotland, United Kingdom

Dr. Alfio Ferlito Dr. Michael Wink

Professor Department of Surgical Sciences Ph.D., Technical University Braunschweig, Germany

University of Udine School of Medicine, Italy Head of Department Institute of Pharmacy and Molecular
Biotechnology, Heidelberg University, Germany

Dr. Jixin Zhong Dr. Pejcic Ana

Department of Medicine, Affiliated Hospital of
Assistant Medical Faculty Department of Periodontology
Guangdong Medical College, Zhanjiang, China, Davis
and Oral Medicine University of Nis, Serbia
Heart and Lung Research Institute, The Ohio State
University, Columbus, OH 43210, US

Rama Rao Ganga Dr. Ivandro Soares Monteiro

MBBS
M.Sc., Ph.D. in Psychology Clinic, Professor University of
MS (Universty of Health Sciences, Vijayawada, India)
Minho, Portugal
MRCS (Royal Coillege of Surgeons of Edinburgh, UK)
United States

Dr. Izzet Yavuz Dr. Sanjay Dixit, M.D.

MSc, Ph.D., D Ped Dent. Director, EP Laboratories, Philadelphia VA Medical Center
Associate Professor, Pediatric Dentistry Faculty of Cardiovascular Medicine - Cardiac Arrhythmia
Dentistry, University of Dicle Diyarbakir, Turkey Univ of Penn School of Medicine
Web: pennmedicine.org/wagform/MainPage.aspx?

Sanguansak Rerksuppaphol Antonio Simone Laganà

Department of Pediatrics Faculty of Medicine M.D. Unit of Gynecology and Obstetrics

Srinakharinwirot University Department of Human Pathology in Adulthood and
NakornNayok, Thailand Childhood “G. Barresi” University of Messina, Italy
 Dr. Han-Xiang Deng Dr. Pina C. Sanelli
MD., Ph.D Associate Professor of Radiology
Associate Professor and Research Department Associate Professor of Public Health
Division of Neuromuscular Medicine Weill Cornell Medical College
Davee Department of Neurology and Clinical Associate Attending Radiologist
Neurosciences NewYork-Presbyterian Hospital
Northwestern University Feinberg School of Medicine MRI, MRA, CT, and CTA
Web: neurology.northwestern.edu/faculty/deng.html Neuroradiology and Diagnostic Radiology
M.D., State University of New York at Buffalo,
School of Medicine and Biomedical Sciences
Web: weillcornell.org/pinasanelli/

Dr. Roberto Sanchez Dr. Michael R. Rudnick

Associate Professor M.D., FACP

Department of Structural and Chemical Biology Associate Professor of Medicine
Mount Sinai School of Medicine Chief, Renal Electrolyte and Hypertension Division (PMC)
Ph.D., The Rockefeller University Penn Medicine, University of Pennsylvania
Web: mountsinai.org/ Presbyterian Medical Center, Philadelphia
Nephrology and Internal Medicine
Certified by the American Board of Internal Medicine
Web: uphs.upenn.edu/

Dr. Feng Feng Dr. Seung-Yup Ku

Boston University M.D., Ph.D., Seoul National University Medical College,

Microbiology Seoul, Korea Department of Obstetrics and Gynecology
72 East Concord Street R702 Seoul National University Hospital, Seoul, Korea
Duke University
United States of America

Dr. Hrushikesh Aphale Santhosh Kumar

MDS- Orthodontics and Dentofacial Orthopedics. Reader, Department of Periodontology,

Fellow- World Federation of Orthodontist, USA. Manipal University, Manipal

Gaurav Singhal Dr. Aarti Garg

Master of Tropical Veterinary Sciences, currently Bachelor of Dental Surgery (B.D.S.) M.D.S. in Pedodontics
pursuing Ph.D in Medicine and Preventive Dentistr Pursuing Phd in Dentistry
 Sabreena Safuan Arundhati Biswas
Ph.D (Pathology) MSc (Molecular Pathology and MBBS, MS (General Surgery), FCPS,
Toxicology) BSc (Biomedicine) MCh, DNB (Neurosurgery)

Getahun Asebe Rui Pedro Pereira de Almeida

Veterinary medicine, Infectious diseases, Ph.D Student in Health Sciences program, MSc in Quality
Veterinary Public health, Animal Science Management in Healthcare Facilities

Dr. Suraj Agarwal Dr. Sunanda Sharma

Bachelor of dental Surgery Master of dental Surgery in B.V.Sc.& AH, M.V.Sc (Animal Reproduction,
Oromaxillofacial Radiology. Obstetrics & gynaecology),
Diploma in Forensic Science & Oodntology Ph.D.(Animal Reproduction, Obstetrics & gynaecology)

Osama Alali Shahanawaz SD

PhD in Orthodontics, Department of Orthodontics, Master of Physiotherapy in Neurology PhD- Pursuing in
School of Dentistry, University of Damascus. Damascus, Neuro Physiotherapy Master of Physiotherapy in Hospital
Syria. 2013 Masters Degree in Orthodontics. Management

Prabudh Goel Dr. Shabana Naz Shah

MCh (Pediatric Surgery, Gold Medalist), FISPU, FICS-IS PhD. in Pharmaceutical Chemistry

Raouf Hajji Vaishnavi V.K Vedam

MD, Specialty Assistant Professor in Internal Medicine Master of dental surgery oral pathology

Surekha Damineni Tariq Aziz

Ph.D with Post Doctoral in Cancer Genetics PhD Biotechnology in Progress

Contents of the Issue

i. Copyright Notice
ii. Editorial Board Members
iii. Chief Author and Dean
iv. Contents of the Issue

1. An Extended Concept of Dental Caries and Update of Cariology

Terminology. 1-5
2. Comparative Study between Endoscopic Assisted Microdebrider
Adenoidectomy (EAMA) and Endoscopic Assisted Coblation Adenoidectomy
(EACA): Analyzing the Intraoperative Parameters & Post-Operative
Recovery. 7-20
3. Orthopantomogram as an Assessment Tool for Identifying Growth Pattern– A
Radiographic Study. 21-25
4. Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution
Times. A Review of the Literature. 27-38

v. Fellows
vi. Auxiliary Memberships
vii. Preferred Author Guidelines
viii. Index
 Global Journal of Medical Research: J
Dentistry & Otolaryngology
Volume 22 Issue 2 Version 1.0 Year 2022
Type: Double Blind Peer Reviewed International Research Journal
Publisher: Global Journals
Online ISSN: 2249-4618 & Print ISSN: 0975-5888

An Extended Concept of Dental Caries and Update of

Cariology Terminology
By Ana María Acevedo, Alejandra Garcia-Quintana,
Annabella Frattaroli-Pericchi & Sonia, Feldman
Universidad Central de Venezuela
Abstract- Recent terminology explains dental caries through an understanding of factors that
interplay in its etiology; however, the focus is still overpowered by the disease at advanced
stages. The aims: (1) extend the concept of dental caries, through the Dental Caries Integrated
Ecological Hypothesis (DCIEH), to one that includes the complexity of the disease with its
conjoint elements during development and progression, and (2) update cariology terminology.
The term: dental caries corresponds to the disease, and dental caries lesion corresponds to the
expression of the disease. Dental caries follows a sequence of progressive phases (mild to
severe), characterized by microbiome dysbiosis of the dental biofilm, including the disturbance
of the metabolic activity of its commensal microbiota, producing an acid-base imbalance.
Dysbiosis is determined by the complex relationship of influential factors regulated by biological
features, modulated by behavior, and conditioned by the environment. A severe chronic
imbalance leads to complete oral homeostasis disruption echoed in a dynamic interaction
between the tooth surface and the dental biofilm with subsequent mineral loss.
Keywords: cariology, terminology, dental caries, dental caries lesion.
GJMR-J Classification: DDC Code: E LCC Code: PN1997

AnExtendedConceptofDentalCariesandUpdateofCariologyTerminology
Strictly as per the compliance and regulations of:

© 2022. Ana María Acevedo, Alejandra Garcia-Quintana, Annabella Frattaroli-Pericchi & Sonia, Feldman. This research/review
article is distributed under the terms of the Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0). You
must give appropriate credit to authors and reference this article if parts of the article are reproduced in any manner. Applicable
licensing terms are at https://creativecommons.org/licenses/by-nc-nd/4.0/.
 An Extended Concept of Dental Caries and
Update of Cariology Terminology
Ana María Acevedo α, Alejandra Garcia-Quintana σ, Annabella Frattaroli-Pericchi ρ & Sonia, Feldman Ѡ

Abstract- Recent terminology explains dental caries through an II. Discussion

understanding of factors that interplay in its etiology; however,
the focus is still overpowered by the disease at advanced The current definition of dental caries as a
stages. The aims: (1) extend the concept of dental caries, disease states that it is a “biofilm-mediated, diet
through the Dental Caries Integrated Ecological Hypothesis
modulated, multifactorial, non-communicable, dynamic

2022
(DCIEH), to one that includes the complexity of the disease
with its conjoint elements during development and disease resulting in net mineral loss of dental hard
tissues. It is determined by biological, behavioral,

Year
progression, and (2) update cariology terminology. The
term: dental caries corresponds to the disease, and dental psychosocial, and environmental factors. As a
caries lesion corresponds to the expression of the consequence of this process, a caries lesion 1
disease. Dental caries follows a sequence of progressive develops”.1 Extending this idea, a concept that

J ) Volume XXII Issue II Version I

phases (mild to severe), characterized by microbiome communicates the complexity of the disease with its
dysbiosis of the dental biofilm, including the disturbance of the conjoint elements during development and progression,
metabolic activity of its commensal microbiota, producing an is immersed in the Dental Caries Integrated Ecological
acid-base imbalance. Dysbiosis is determined by the complex
Hypothesis (DCIEH).2
relationship of influential factors regulated by biological
features, modulated by behavior, and conditioned by the The DCIEH integrates Microbial-Biochemical-
environment. A severe chronic imbalance leads to complete Environmental-Behavioral (MBEB) factors in a 4-phased
oral homeostasis disruption echoed in a dynamic interaction process, which ranges from mild to severe, to
between the tooth surface and the dental biofilm with understand the complexity of the early establishment of
subsequent mineral loss. An individual dental caries health and comprehend decisive factors involved in the
free should imply that the disease is not present. onset and progression of dental caries. The phases
Instead, dental caries lesion free suggests the absence, after (dynamic stability, mild, moderate, and severe
thorough evaluation, of a visible clinical expression at any
dysbiosis) follow a logical order of event occurrence and
lesion stages (from non-cavitated to cavitated lesion). This
extended concept allows for a broader understanding of the consider MBEB factors and processes including:

Global Journal of Medical Research ( D

complexity of the disease. It provides a basis for knowledge to homeostatic mechanisms in the dental biofilm, the
develop tailored strategies that may address the existing relationship between dental biofilm and microbiota, acid
condition of the disease and its progression. and base metabolic pathways, saliva composition and
Keywords: cariology, terminology, dental caries, dental functions, the role of the salivary pellicle, epigenetic
caries lesion. modifiers, dietary and nutritional influences, the
importance of maternal psychosocial and behavioral
I. Introduction modulators, and predisposing, reinforcing and enabling

F
or the most part, throughout history, there has environmental conditions.2
been no clear separation between the Under the scope of the DCIEH, the term dental
terminologies used for dental caries disease and caries corresponds to the disease characterized by
dental caries lesion. Although the set of agreed microbiome dysbiosis of the dental biofilm, including the
concepts1 attempting to explain dental caries disease disturbance of the metabolic activity of its normal,
has included a more comprehensive understanding of commensal, and resident microbiota. Such alteration is
the factors that interplay in its complex etiology, the reflected in the quantity and type of organic acid
focus is still overpowered by the disease at advanced production and the insufficient generation of alkaline
stages; hence an extended concept is needed. substances. Dysbiosis is determined by the complex
relationship of a series of influential factors, regulated by
Author α: DDS, MSc, PhD. Universidad Central de Venezuela, Facultad
de Odontología, Instituto de Investigaciones Odontológicas Raúl
biological features, modulated by behavior, and
Vincentelli, Caracas, Venezuela. conditioned by the environment.2
Corresponding Author σ: DDS, MPH candidate. University of Texas The term dental caries lesion corresponds to the
Health and Science Center at Houston, Department of Health
Promotion and Behavioral Sciences, Houston, Texas.
expression of the disease. The chronic persistence of
e-mail: [email protected] microbiome imbalance and altered dental biofilm
Author ρ: Dental Student. Universidad Central de Venezuela, Facultad conditions leads to the disruption of oral health
de Odontología, Caracas, Venezuela. homeostasis echoed in a dynamic interaction
Author Ѡ: DDS, Pediatric Dentist Specialty. Complejo Social Don
Bosco, Caracas, Venezuela.
(demineralization-remineralization) between the tooth

© 2022 Global Journals

 An Extended Concept of Dental Caries and Update of Cariology Terminology

surface and the dental biofilm. Once the disease given that it is immersed in the latest stage of dental
reaches a moderate phase (under uncontrolled caries lesion.
conditions), a mineral loss occurs in the tooth structure From this understanding, it is essential to
(initial lesion) at a subclinical stage. The initial lesion acknowledge that determining an individual as dental
could be completely reversed if the environment of the caries free is very difficult. The only approximation we
dental microbiome shift towards a healthy state. As have to obtain information about the presence of the
unfavorable conditions prevail, a severe phase of the disease is the risk assessment.26,27 However, no clear
disease is then expressed as a clinically detectable indication of its degree of severity can be concluded
lesion.2 with the existing tools. Therefore, clinical research must
It is essential to emphasize the difference focus on developing methods to detect the presence
between dental caries and its expression understood as and severity of the disease accurately.
dental caries lesion. The combined usage of disease Historically, what has been developed are
and lesion in the simple term “caries” has created criteria and indexes to detect and quantify dental caries
2022

confusion when distinguishing that the disease pertains lesions, mainly assessing the late stages of lesion
to the individual. In contrast, the lesion relates to the progression (cavitation).28 Until recently, the status of
Year

hard tissues of the tooth.3-8 Under this extended dental caries in its different phases at the population
concept, dental caries disease shares common risk level (from local to national) remains unknown.
2 factors with other non-communicable diseases (e.g., Generally, epidemiological profiles reported the
obesity, diabetes, cardiovascular disease, cancer, prevalence of dental caries lesion with criteria that only
J ) Volume XXII Issue II Version I

autoimmune disease).9,10 Despite the efforts to manage reflected its severe stage.29-30 In 2005, the International
such conditions, the complexity they convey has not Caries Detection and Assessment System (ICDAS)31
allowed their effective management, possibly due to the developed a more accurate clinical scoring system to
limited understanding of the upstream etiology.11-14 In detect and assess dental caries lesions before
contrast, most research and clinical action have been cavitation at various tooth surfaces.32,33
evocated to treat their signs and symptoms, as non- This last system allows the detection of the
communicable diseases remain the leading causes of disease at a severe phase but at an earlier stage of its
death and disability globally.15,16 expression (non-cavitated dental caries lesion).
As is the case in dentistry, little to none has However, no system is available to detect the early
been proposed to understand dental caries from its phases of the disease (mild and moderate) because the
origin to its management. Meanwhile, all efforts have clinical expression is not yet evident on the tooth surface
been directed to detect and treat dental caries lesions.17- during these phases.2 Detecting a dental caries lesion
24
However, poor outcomes and no success are evident during the early stages of expression indicates that the
Global Journal of Medical Research ( D

given that the severe disease, masked by lesions, individual has the disease; however, the absence of a
continues to be a public health problem worldwide.11 No dental caries lesion does not mean that the individual is
scientific evidence is yet comprehensive enough to free of the disease. Hence, it is essential to highlight that
depict the effectiveness of dental treatments as the detection of dental caries lesion alone generates a
measures to address the disease; instead, these actions sub-registry of dental caries as a disease in the entire
are procedures to mitigate lesion progression.25 Hence, population.34 Prevalence results of dental caries lesions
based on evidence, wide-ranging strategies and policies are not an accurate parameter to assess the condition;
are necessary to jointly manage the disease and its thus, under the DCIEH, it becomes necessary to include
impact.11-13 the analysis of all the factors (MBEB) that indicate an
Based on this rationale, the term “caries free” individual suffers the disease but does not manifest it.2
and “cavity free” needs to be clarified. As previously Such an approach paves the way to design, plan and
mentioned, the term “caries” alone is subject to implement overarching strategies that address the onset
confusion; thus, it is necessary to expand the concept to and progression of the disease.35
one that differentiates the disease (dental caries) and its Most of the research has focused on the
clinical expression (dental caries lesion). By recent secondary and tertiary management (e.g., dental
consensus, “caries free implies that there are no material and instrument technology, non and minimally
detectable signs of dental caries,” and “cavity invasive treatment) of dental caries lesions. As for
free implies that there are no detected cavities in disease management, scarce scientific evidence has
dentine.”1 However, these concepts analyzed under the been published regarding a comprehensive approach to
DCIEH suggest that an individual “dental caries health and disease prevention; moreover, sugar intake
free” should imply that the disease is not present. and dental hygiene have been the focus.11,12
Instead, “dental caries lesion free” indicates the This extended concept of dental caries (Figure
absence, after thorough evaluation, of a visible clinical 1) allows for a broader understanding of the complexity
expression at any lesion stages (from non-cavitated to of the disease. This approach provides a basis for
cavitated lesion).2 The term “cavity free” is dispensable knowledge applicable to develop tailored strategies that

© 2022 Global Journals

 An Extended Concept of Dental Caries and Update of Cariology Terminology

may address the existing condition of the disease and 10. World Health Organization. Oral health fact sheet.
its progression. Such an approach should cover public 2022. Accessed: 7 July 2022. Retrieved from:
health policies, health promotion programs, https://www.who.int/news-room/fact-sheets/detail/
environmental change, behavioral and biological oral-health
interventions, patient-centered practices, and clinical 11. Peres MA, Macpherson LMD, Weyant RJ, et al. Oral
management. diseases: a global public health challenge
[published correction appears in Lancet. 2019 Sep
III. Conclusion 21; 394(10203): 1010]. Lancet. 2019; 394(10194):
Finally, we encourage academies, associations, 249-260. doi: 10.1016/S0140-6736(19)31146-8
and researchers to join consensus on the terminology 12. Watt RG, Daly B, Allison P, et al. Ending the neglect
used to define dental caries and all it encompasses. of global oral health: time for radical action. Lancet.
Also, we recommend that research advancement 2019; 394(10194): 261-272. doi:10.1016/S0140-
focuses on developing instruments and methods for 6736(19)31133-X

2022
disease identification (from its onset to progression). 13. McNeil DW, Randall CL, Baker S, et al. Consensus
Lastly, a comprehensive approach should lead to Statement on Future Directions for the Behavioral

Year
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11068033 3
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4511435328 2022.vol36.0026.
25. Horst JA, Tanzer JM, Milgrom PM. Fluorides and 35. Garcia-Quintana A, Shegog R, Hebert ET, Young M,
Other Preventive Strategies for Tooth Decay. Dent Frattaroli-Pericchi A, Feldman S, Acevedo AM. A
Clin North Am. 2018 Apr; 62(2): 207-234. doi: Conceptual Framework of Maternal Behaviors and
10.1016/j.cden.2017.11.003. PMID: 29478454; Early Childhood Caries. In: International Association
PMCID: PMC5830181. for Dental Research 100th General Session. June
26. Martignon S, Roncalli AG, Alvarez E, Aránguiz V, 20-25, 2022. China. Abstract # 3722897.
Feldens CA, Buzalaf MAR. Risk factors for dental 36. Ismail AI, Pitts NB, Tellez M, et al. The International
caries in Latin American andCaribbean countries. Caries Classification and Management System
Braz Oral Res. 2021; 35(suppl 1): e053. https:// (ICCMS™) An Example of a Caries Management
doi.org/10.1590/1807-3107bor-2021.vol35.0053 Pathway. BMC Oral Health. 2015; 15 Suppl 1(Suppl
1): S9. doi: 10.1186/1472-6831-15-S1-S9.
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27. Gao XL, Hsu CY, Xu Y, Hwarng HB, Loh T, Koh D.

Building caries risk assessment models for children.
J Dent Res.2010 Jun; 89(6): 637-43. https://doi.org/
10.1177/0022034510364489
28. World Health Organization- WHO. WHO oral health
surveys: basic methods. 5th ed. Monts: WHO; 2013.
p. 42-7.
29. GBD 2017 Oral Disorders Collaborators. Global,
regional, and national levels and trends in Burden of
oral conditions from 1990 to 2017: a systematic
analysis for the Global Burden of Disease 2017
study. J Dent Res. 2020; 99(4): 362-373.
https://doi.org/10.1177/0022034520908533
30. Bernabe E, Marcenes W, Hernandez CR, Bailey J,
Abreu LG, Alipour V, et al. Global, regional, and
national levels and trends in burden of oral
conditions from 1990 to 2017: a systematic analysis
for the Global Burden of Disease 2017 Study. J Dent
Res. 2020 Apr; 99(4): 362-73. https://doi.org/
10.1177/0022034520908533
31. International Caries Detection and Assessment
System (ICDAS) Coordinating Committee. Criteria
Manual–International Caries Detection and
Assessment System (ICDAS II). [Internet] Scotland:
Dental Health Services Research Unit; 2005.

© 2022 Global Journals

 An Extended Concept of Dental Caries and Update of Cariology Terminology

2022 Year
51

J ) Volume XXII Issue II Version I

Figura 1: A schematic representation of the extended concept of dental caries.
A. Comprehensive Dental Caries assessment and Management correspond to evaluation, classification, diagnosis
and management for dental caries (current research proposal).
*Acevedo AM, Garcia-Quintana A, Frattaroli-Pericchi, Feldman S. 2022.
B. The International Caries Classification and Management System - ICCMSTM as key elements for dental caries
lesion management.
**Ismail AI et al. 2015.

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2022 Year

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 Global Journal of Medical Research: J
Dentistry & Otolaryngology
Volume 22 Issue 2 Version 1.0 Year 2022
Type: Double Blind Peer Reviewed International Research Journal
Publisher: Global Journals
Online ISSN: 2249-4618 & Print ISSN: 0975-5888

Comparative Study between Endoscopic Assisted

Microdebrider Adenoidectomy (EAMA) and Endoscopic
Assisted Coblation Adenoidectomy (EACA): Analyzing the
Intraoperative Parameters & Post-Operative Recovery
By Dr. Shrinivas S. Chavan, Dr. Naveen Kumar Singh, Dr. Vitthal D. Kale,
Dr. Abhishek D. Khond, Dr. Elton C. Mendonca & Dr. Priyanka Singh
Abstract- Background: Adenoid hypertrophy is one of the most common causes of nasal
blockage in childrento seek an otorhinolaryngologist, which is often presented as recurrent acute
otitis media, sleep disordered breathing including obstructive sleep apnea (OSA), hypo apnea
syndrome and chronic rhinosinusitis. Surgical adenoidectomy is a common Otolaryngology
procedure recommended in children with adenoid hypertrophy not responding to medical line of
management. Conventional adenoidectomy is performed blindly without visualizing the
nasopharynx; which leads to complications like inadequate adenoid tissue removal, eustachian
tube scarring, bleeding. This has led to development of alternate surgical methods with
visualization of nasopharynx via nasal endoscopes. With the recent introduction of microdebrider
and coblation in rhino surgery many surgeons prefer endoscopic guided microdebrider
adenoidectomy and endoscopic guided coblation adenoidectomy.
Keywords: nasal obstruction, adenoid hypertrophy, adenoidectomy, microdebrider, coblation.
GJMR-J Classification: DDC Code: E LCC Code: RF484.5

ComparativeStudybetweenEndoscopicAssistedMicrodebriderAdenoidectomyEAMAandEndoscopicAssistedCoblationAdenoidectomyEACAAnalyzingtheIntraoperativeParametersPostOperativeRecovery
Strictly as per the compliance and regulations of:

© 2022. Dr. Shrinivas S. Chavan, Dr. Naveen Kumar Singh, Dr. Vitthal D. Kale, Dr. Abhishek D. Khond, Dr. Elton C. Mendonca &
Dr. Priyanka Singh. This research/review article is distributed under the terms of the Attribution-NonCommercial-NoDerivatives 4.0
International (CC BY-NC-ND 4.0). You must give appropriate credit to authors and reference this article if parts of the article are
reproduced in any manner. Applicable licensing terms are at https://creativecommons.org/licenses/by-nc-nd/4.0/.
 Comparative Study between Endoscopic Assisted
Microdebrider Adenoidectomy (EAMA) and
Endoscopic Assisted Coblation Adenoidectomy
(EACA): Analyzing the Intraoperative Parameters &
Post-Operative Recovery
Dr. Shrinivas S. Chavan α, Dr. Naveen Kumar Singh σ, Dr. Vitthal D. Kale ρ, Dr. Abhishek D. Khond Ѡ,

2022
Dr. Elton C. Mendonca ¥ & Dr. Priyanka Singh §

Year
Abstract- Background: Adenoid hypertrophy is one of the most still we can conclude that endoscopic assisted coblation
common causes of nasal blockage in childrento seek an adenoidectomy (EACA) produce better results in treatment of 7
otorhinolaryngologist, which is often presented as recurrent adenoid hypertrophy not relieved with medical line of

J ) Volume XXII Issue II Version I

acute otitis media, sleep disordered breathing including management both in intra operative and post operative
obstructive sleep apnea (OSA), hypo apnea syndrome and parameters as compared to endoscopic assisted
chronic rhinosinusitis. Surgical adenoidectomy is a common microdebrider adenoidectomy (EAMA). Limitations of this
Otolaryngology procedure recommended in children with study was that different causes of adenoid hypertrophy were
adenoid hypertrophy not responding to medical line of not taken into consideration and adenoid hypertrophy with
management. Conventional adenoidectomy is performed associated symptoms not responding to medical line of
blindly without visualizing the nasopharynx; which leads to management between the age group of 5 to 15 years were
complications like inadequate adenoid tissue removal, included in this study. Another limitation of this study was that
eustachian tube scarring, bleeding. This has led to objective method of nasal patency assessment like
development of alternate surgical methods with visualization of rhinomanometry was not used due to cost restraints and
nasopharynx via nasal endoscopes. With the recent instead subjective method of visual analog scale of 10-point
introduction of microdebrider and coblation in rhino surgery scale was used for the same. A more elaborate larger
many surgeons prefer endoscopic guided microdebrider randomized studies with use of rhinomanometry would
adenoidectomy and endoscopic guided coblation definitely be helpful to confirm or refute the same.

Global Journal of Medical Research ( D

adenoidectomy. Keywords: nasal obstruction, adenoid hypertrophy,
Aim: To compare intra operative parameters and post adenoidectomy, microdebrider, coblation.
operative recovery in patients undergoing endoscopic
assisted microdebrider adenoidectomy (EAMA) and I. Introduction
endoscopic assisted coblation adenoidectomy (EACA).

I
Methods and results: A prospective interventional comparative n today’s era adenoidectomy & tonsillectomy are the
clinical study between endoscopic assisted microdebrider two most commonly performed pediatric
adenoidectomy (EAMA) and endoscopic assisted coblation otorhinolaryngological procedures and are associated
adenoidectomy (EACA) was conducted. A total of 30 patients with variety of potential complications [1-3] As we all
were included in the study. Patients were randomized in pool A know adenoids exist as a rectangular mass of lymphatic
and pool B by random number allocation technique. Patients tissue in the nasopharynx. Meyer first described this
in pool A underwent EAMA and in pool B underwent EACA. mucosa-associated lymphoid tissue in 1868 [4].They
Comparisons were made between pre and post operative form part of the Waldeyer’s ring. Adenoids with other
endoscopic grades of adenoids, pre and post operative relief
lymphatic tissue in the nasopharynx act as the first line
of associated symptoms of adenoid hypertrophy, intra
operative time, intra operative blood loss along and post of defense against ingested or inhaled pathogens.[1][2]
operative pain, results were statistically significant for EACA. Adenoid hypertrophy is more common in children than
Conclusion: Even though the comfort and adequate training of in adults. In children, the prevalence of adenoid
surgeon as well as cost affordability by the patients would hypertrophy has been estimated at 34.5 percent [5].
determine the choice of technique to be used for endoscopic Adenoid’s hypertrophy occurs physiologically in children
guided adenoidectomy over conventional method as both the between the age of 6–10 years, then later regresses by
procedures compared in our study do justice in the the age of 16 years [6].
completeness of removal as well as in rate of complications

Author σ: Department of Otorhinolaryngology, Grant Government

Medical College and Sir J.J. group of hospitals, Mumbai, India.
e-mail: [email protected]

© 2022 Global Journals

 Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery
2022 Year

8
Figure 1: Adenoid hypertrophy Figure 2: Endoscopic view enlargedadenoids
J ) Volume XXII Issue II Version I
Global Journal of Medical Research ( D

Figure 3: Lateral soft tissue radiograph X-raynasopharynx

Adenoid hypertrophy is an obstructive Basic principle of adenoidectomy surgery is to
condition, with its symptomatology depending on the debulk the hypertrophied adenoids and to decrease
obstructed structure. Nasal obstruction by hypertrophic associated obstructive symptoms. The conventional
adenoid tissue can cause rhinorrhea, difficulty breathing adenoidectomy using saint claire Thompson adenoid
through the nose, post-nasal drip, snoring, and/or sleep- curette was first described in 1885 [6]. This procedure is
disordered breathing in children like Obstructive Sleep performed blindly without visualizing the nasopharynx;
Apnea (OSA) and hypo apnea syndrome. If the nasal which leads to uncommon complications such as
obstruction is significant, the patient can suffer from inadequate adenoid tissue removal, eustachian tube
sinusitis as a result and may complain of facial pain. scarring, bleeding and nasopharyngeal stenosis. This
Obstruction of the Eustachian tube can lead to has led to development of alternate surgical method
symptoms consistent with Eustachian tube dysfunction where visualized resection of adenoid tissue can be
such as muffled hearing, otalgia, and/or recurrent done like endoscopic assisted adenoidectomy.
middle ear infections [7]. Although in many cases, the Canon et al. [1] popularized endoscopic
adenoid hypertrophy regresses with age but some assisted adenoidectomy (EAA) calling it “natural
cases require active intervention. Initially, these cases progression of endoscopic technology to allow a more
are managed medically but sometimes surgical complete adenoidectomy”.
intervention in form of adenoidectomy becomes With advent of endoscopic assisted
mandatory in patients not responding to medical adenoidectomy many newer techniques have been
management. used for surgical debridement of adenoid tissue which
includes microdebrider, diathermy, coblation. Because

© 2022 Global Journals

Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

of the availability of varied techniques of surgical radiological evidence of adenoid hypertrophy.

debridement under endoscopic guidance there is lack Diagnostic nasal endoscopy was done to rule out any
of consensus for optimal endoscopic assisted other endonasal pathology other than adenoid
adenoidectomy (EAA). Hence in this study we would like hypertrophy and grades of adenoid hypertrophy were
to compare and contrast endoscopic assisted documented.
microdebrider adenoidectomy (EAMA) and endoscopic A total of 112 patients with above symptoms
assisted coblation adenoidectomy (EACA). were screened and examined out of which 69 patients
were found to have adenoid hypertrophy. All these
II. Study Design patients were subjected to medical line of management
This is a prospective interventional and in form of topical and oral nasal decongestants along
comparative study conducted between December 2020 with topical corticosteroids nasal spray. Among these 36
to December 2021 in Department of patients responded to medical line of management after
Otorhinolaryngology, Grant Government Medical 6 weeks. Remaining 33 patients were thoroughly
explained about their condition, and were given an

2022
College and Sir J.J. group of Hospitals, Mumbai, India.
option of adenoidectomy under this study design,
a) Inclusion criteria procedure to be performed, associated risks& need for

Year
1. Male and female individuals of age 5 years to 15 postoperative follow up. So out of the 33 patients 3
years suffering from associated symptoms due to patients gave negative consent for surgery, remaining 9
adenoid hypertrophy and not getting relieved with 30 patients after receiving informed valid written consent

J ) Volume XXII Issue II Version I

medical line of management. were randomized into two pools based on random
2. Individuals presenting with symptoms of chronic number allocation technique. Patients with odd number
mouth breathing, snoring, persistent nasal were allocated into POOL-A, where the patients
discharge, recurrent upper respiratory tract underwent endoscopic assisted microdebrider
infection, recurrent acute suppurative otitis media adenoidectomy (EAMA) with irrigating blades of angle
and adenoid facies. 45 degrees. Patients with even number were allocated
3. Individuals with radiological and endoscopic into POOL-B, where the patients underwent endoscopic
evidence of adenoid hypertrophy. assisted coblation adenoidectomy (EACA) with
4. Individuals willing to enroll in the study meeting the PROCISE MAX wand. All the patients were operated by
above criteria. the same surgeon who was blinded with respect to
study designs and study details.
b) Exclusion criteria
Diagnostic nasal endoscopies of pool A and
1. Individuals with congenital facial anomalies like cleft
pool B along with data analysis for pre-operative and
lip, cleft palate etc.

Global Journal of Medical Research ( D

post-operative gradings of adenoid hypertrophy was
2. Individuals with other nasal pathology like Sino
performed by same investigator. Intra operative time for
nasal polyposis, Sino nasal mass etc.
adenoid excision, along with blood loss was noted and
3. Individuals with syndromes like Down’s syndrome
compared. Pre-operative clinical signs and symptoms
etc.
were compared with post-operative clinical signs and
4. Previously operated individuals for the similar
symptoms. All the patients in pool A and pool B
pathology.
received the same post-operative care. Patients were
5. Individual with bleeding disorders like sickle cell
examined on 2nd, 7th,15th and 30th post-operative day for
anemia, abnormal coagulation profile.
signs and symptoms with post-operative nasal
6. Individuals not willing to enroll in the study.
endoscopy for grading of adenoids. Patients were
c) Methodology and techniques examined for pre- and post-surgery for nasal patency
Patients attending Otorhinolaryngology OPD in percentage based on visual analogue scale score (VAS
Grant Government Medical College and Sir J.J. Group Score)- patients were instructed to indicate the point on
of Hospitals, Mumbai, India with complaints of the scale (1-10) that best corresponds to their severity of
rhinorrhea, post-nasal drip, mouth breathing, snoring, nasal obstruction, higher score indicates worse
sleep-disordered breathing, recurrent middle ear obstruction.
infections, recurrent upper respiratory tract infections Visual Analogue Scale (VAS). VAS score out of 10 X10=
and adenoid facies were initially screened based on VAS Score out of 100.
inclusion and exclusion criteria as stated before. After
screening, chosen patients were subjected to detailed
clinical history followed by thorough clinical ENT
examination after taking informed valid written consent.
During ENT examination patients showing bulge / soft
tissue mass in nasopharynx during posterior rhinoscopy
were subjected to X ray nasopharynx lateral view for

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 Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

Figure 4: Visual Analogue Scale for nasal patency percentage

2022

Post operative pain was also measured on anchor points of no pain and worst pain imaginable
Year

follow up days i.e. 2nd, 7th, 15th and 30th based on Visual which is self-assessed by patient.
Analogue Scale. It consists of a 10 cm line with two
10
J ) Volume XXII Issue II Version I
Global Journal of Medical Research ( D

Figure 5: Visual Analogue Scale for post operative pain

d) Procedure cavity for 5 minutes. After hemostasis is achieved, post

All procedures were performed under general nasal pack is removed under direct vision.
anesthesia. Patients taken in supine position, painted
and draped. Zero degree endoscope with a video
attachment is introduced through nose and grade of
adenoid hypertrophy noted and accordingly.
In Pool A,0-degree endoscope is introduced
through the nose to visualize the nasopharynx,
microdebrider with a 45 degrees curved blade with
cutting window of which is on the convex side, is also
introduced through the mouth. The instrument is
connected to an aspirator and is programmed to
alternate rotations, with a rotational speed of 1200 rpm.
Removal of the adenoid tissue starts from the choanal
vegetations and proceeds backwards along the vault
towards the posterior wall of the nasopharynx. At the
end of the resection, a post nasal pack is placed in that

© 2022 Global Journals

Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

Figure 6: Endoscopic view of microdebrider blade and its position

2022
In Pool B, 0-degree endoscope is introduced was made sure that wand is carefully inserted and
along with coblation PROCISE MAX wand, which is removed without injury to uvula or soft palate.

Year
connected to the controller with the default settings of 7 Endoscopic check of nasopharynx was
and 3 on the coblation and coagulation LEDs performed to ensure removal of all adenoid tissue. And
respectively. Foot pedal ablation of the adenoid tissue if any bleeding areas were present, then they were 11
was activated as soon as the wand is close to the coagulated with the wand by pressing directly on the

J ) Volume XXII Issue II Version I

inferior edge of the adenoid, avoiding direct contact. It bleeder for 2-3 seconds.

Figure 7: Procise Max Wand

Global Journal of Medical Research ( D

Figure 8: Endoscopic view of coblator during start of adenoidectomy and post adenoidectomy
In both pools A and B, at the end of procedure software for statistical analysis. Quantitative data was
intra operative time, intra operative blood loss was presented as mean and standard deviation and
recorded check nasal endoscopy was done for any comparison of the two study groups was done using
residual adenoid tissue and for any bleeding points. unpaired t-Test. Pre-operative and post -operative
There after similar check nasal endoscopy was done on quantitative data of each surgical technique was
post op day 2before discharging the patient and on compared using paired t-Test. Qualitative data was
subsequent follow ups that is on 7th, 15th 30th day. presented as frequency and percentage and analyzed
Similarly post op pain, post op nasal patency based on using chi-square test. A p-value of < 0.05 was
VAS score was recorded on same follow-up days. considered as statistically significant.
e) Data analysis and statistical tests
All the collected data was entered in Microsoft
Excel sheet. It was then transferred to SPSS ver. 17

© 2022 Global Journals

 Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

III. Observations and Results management were given the option of adenoidectomy
under this study design of which 3 patients gave
In this study of 11 months duration, 112 patients negative consent for surgery, remaining 30 patients after
were assessed in otorhinolaryngology OPD of Grant receiving informed valid written consent were included in
Medical College and Sir JJ group of Hospitals Mumbai, this study.
India, out of which 69 patients were found to have In pool A, 15 patients were operated of which
clinical symptoms because of adenoid hypertrophy and 08 were males and 07 were females. In pool B, 15
thereafter they were subjected to medical line of patients were operated of which 09 were males and 06
management.36 patients responded to medical line of were females.
management of 6 weeks. And remaining 33 patients
whose symptoms didn’t subside with medical line of

Sex Age (years)

2022

9 8
Year

8 7
7 6
12 6 5
5 4
J ) Volume XXII Issue II Version I

3
4
2
3 1
2
5-8 years0 5 4
Male1 8 9 Pool A Pool B
0 9-12 years 6 8
Female 7 A
Pool 6 B
Pool
13-15 years 4 3

Graph 1: Distribution of patients Graph 2: Distribution of patients

according to Sex according to Age

Overall, mean age in Pool A was 10.20 ± 3.14

Global Journal of Medical Research ( D

years and in Pool B was 10.27 ± 2.40 years (Graph 2).

a) Visual Analogue Scale (VAS) Score
In this study, VAS score is used for evaluation of
Pre and post op nasal patency along with post op pain.
Nasal Patency: The mean pre-operative VAS score
percentage in pool A was 84.60% whereas in pool B
was 92.4%. During post-operative follow up, VAS score
percentage in pool A on day 2nd7th, 15th, 30th were 51%,
50%, 27.80% and 26.63% respectively, and in pool B on
aforementioned days were 92.4%,42.30% 40%, 26.70%
and 12.70% respectively (Graph 3). The difference in
VAS score percentage between pre-op and post-op
values in both the groups was statistically significant as
per ANOVA test (p<0.05).

© 2022 Global Journals

Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

100.00%

80.00%

60.00%

40.00%

20.00%

0.00%
Pool A Pool B
Pre-op

2022
84.60% 92.40%
Post-op Day 2 51% 42.30%

Year
Post-op Day 7 50% 40%
Post-op Day 15 27.80% 26.70% 13
Post-op Day 30 26.63% 12.70%

J ) Volume XXII Issue II Version I

Pre-op Post-op Day 2 Post-op Day 7 Post-op Day 15 Post-op Day 30

Graph 3: Distribution of patients according to nasal patency of airway based on VAS score for nasal obstruction.
VAS score for post operative pain:- Similarly, the mean reduced to 0 for both the pools on subsequent follow up
VAS score for post operative pain on Post op day 2 in days i.e., on post op day 15th and 30th. In both the
pool A was 7.23 +_ 0.51whereas in pool B was techniques VAS Score for post operative pain were
7.48+_0.46. During post-operative follow ups, VAS compared using chi square test and the result of the test
score for post op pain in pool A on day 7th was were statistically not significant with p-value > 0.05.
1.53+_0.26 and in pool B was 1.67+_0.35 which

Postoperative VAS Pain Score

Global Journal of Medical Research ( D

8
7
6
5
4
3
2
1
Post-op Day 02 7.23 7.48
Pool A Pool B
Post-op Day 7 1.53 1.67
Post-op Day 15 0 0
Post-op Day 30 0 0

Post-op Day 2 Post-op Day 7 Post-op Day 15 Post-op Day 30

Graph 4: Distribution of patients according to post operative pain based on VAS score.

© 2022 Global Journals

 Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

b) Duration for surgery duration of surgery was significantly longer in Pool A

Intra operative time taken in both surgery were compared to Pool B as per Student t-test (25.07 ± 3.79
recoded and compared, it was found that mean mins vs. 17.33 ± 2.44 min sp<0.05).

25.07
30
25 17.33
20
15
2022

10
Year

5
14 0
Pool A Pool B
Duration of Surgery (mins)
J ) Volume XXII Issue II Version I

Graph 5: Comparison of Duration of Surgery in both Groups

c) Intra Operative Blood Loss was significantly more in Pool A compared to Pool B as
Similarly, intra operative blood loss calculated per Student t-test (51.27 ± 8.08 ml vs. 24.20 ± 4.74
and it was found that mean intraoperative blood loss mlp<0.05)

Table 1: Comparison of Intraoperative Blood Loss in both Groups

Pool A Pool B
p value
Mean SD Mean SD

Intraoperative Blood
Global Journal of Medical Research ( D

51.27 8.08 24.20 4.74 <0.05

Loss (ml)

Intraoperative Blood Loss (ml)

60 51.27

50

40
24.2
30

20

10

0
Pool A Pool B

Graph 6: Comparison of Intraoperative Blood Loss in both Groups

© 2022 Global Journals

Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

d) Nasal endoscopic findings endoscopy was as following, 5 (33.3%) patients was

During nasal endoscopy of each patient on pre- Grade 2 while it was Grade 3 and Grade 4 in 6 (40%)
operative and post-operative follow up days, Adenoids and 4 (26.7%) patients respectively. In Pool B, the grade
were categorized into the following 4 grades according of the adenoid hypertrophy in 3 (20%) patients was
to the percentage of adenoid tissue that causes the Grade 2 while it was Grade 3 and Grade 4 in 5 (33.3%)
blockage of posterior choana and 7 (46.7%) patients respectively. There was no
Grade I- adenoid tissue obstructs 0% to 25% of significant difference between the groups as per Chi-
posterior choana Square test (p>0.05).
When compared with Post Op Grading on Day
Grade II- adenoid tissue obstructs 26% to 50% of
30 Grade 0 were seen in 5 (33.3%) patients in Pool A
posterior choana
and 9 (60%) patients in Pool B, grade 1 was seen in 4
Grade III- adenoid tissue obstructs 51% to 75% of (26.7%) patients in Pool A and 6 (40%) in Pool B. Grade
posterior choana 2 was only seen in pool A that too also in 6 (40%)
Grade IV- adenoid tissue obstructs 76% to 100% of patients. There was no significant difference between

2022
posterior choana [10] the groups as per Chi-Square test (p>0.05).

Year
e) Grades of adenoid hypertrophy based of nasal
endoscopy
It was observed in our study that Pre operative 15
grading of adenoid hypertrophy in Pool A, by nasal

J ) Volume XXII Issue II Version I

Table 2: Distribution of patients according to Pre-operative Grading of the Adenoids

Pool A Pool B
Pre-operative Grading of the Adenoids p value
N % N %
Grade 1 0 - 0 -

Grade 2 5 33.3% 3 20%

>0.05
Grade 3 6 40% 5 33.3%

Grade 4 4 26.7% 7 46.7%

Global Journal of Medical Research ( D

Table 3: Distribution of patients according to Post-operative Grading of the Adenoids on Day 2, 7, 15 and 30

Post-op Grading of the Adenoids on Pool A Pool B

p value
POD 2 N % N %
Grade 0 3 20% 7 46.7%

Grade 1 10 66.7% 8 53.3%

Grade 2 2 13.3% 0 - >0.05

Grade 3 0 - 0 -
Grade 4 0 - 0 -

Post-op Grading of the Adenoids on Pool A Pool B

p value
POD 7 N % N %
Grade 0 3 20% 7 46.7%

Grade 1 10 66.7% 8 53.3%

Grade 2 2 13.3% 0 - >0.05

Grade 3 0 - 0 -

Grade 4 0 - 0 -

© 2022 Global Journals

 Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

Post-op Grading of the Adenoids Pool A Pool B

p value
on POD 15 N % N %
Grade 0 5 33.3% 9 46.7%

Grade 1 4 26.7% 6 53.3%

Grade 2 6 40% 0 - >0.05

Grade 3 0 - 0 -

Grade 4 0 - 0 -
2022 Year

Post-op Grading of the Pool A Pool B

p value
Adenoids on Day 30 N % N %
16
J ) Volume XXII Issue II Version I

Grade 0 5 33.3% 9 60%

Grade 1 4 26.7% 6 40%

Grade 2 6 40% 0 - >0.05

Grade 3 0 - 0 -

Grade 4 0 - 0 -

f) Pre-Op evaluation of associated symptoms Infection (URTI) and Acute Suppurative Otitis Media
Along with VAS score and nasal endoscopic (ASOM) while 7 (46.7%) patients had general features of
Global Journal of Medical Research ( D

gradings, patients were also evaluated for preoperative the adenoid facies. In Pool B, 12 (80%) patients each
symptoms and relief of those symptoms post showed symptom of mouth breathing and snoring while
operatively. In the present study, pre operatively in Pool 9 (60%) patients had URTI. 8 (53.3%) patients had facial
A all patients showed symptom of mouth breathing features while 7 (46.7%) patients had ASOM. There was
while 10 (66.7%) patients had snoring, 8 (53.3%) no significant difference between the groups as per Chi-
patients each had recurrent Upper Respiratory Tract Square test (p>0.05).
Table 4: Distribution of patients according to Pre-operative Symptoms

Pool A Pool B
Pre-operative Symptoms p value
N % N %

Mouth Breathing 15 100% 12 80%

Snoring 10 66.7% 12 80%

URTI 8 53.3% 9 60% >0.05

ASOM 8 53.3% 7 46.7%

Adenoid facies 7 46.7% 8 53.3%

© 2022 Global Journals

Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

g) Post-Op evaluation of associated symptoms patients (40%) were having complaints of snoring and in
Thereafter, post-operatively on Day 2, 5 (33.3%) pool B, patients complaining of mouth breathing and
patients in Pool A and 2 (13.33%) patients in Pool B still snoring reduced to 1 that is 6.7%.There was no
showed symptom of mouth breathing while 3 (20%) significant difference between the groups as per Chi-
patients in Pool A and 2 (13.33%) patients in Pool B still Square test (p>0.05).
had snoring. URTI was only seen in Pool A that too also Post-operative Day 30, all patients in Pool B
with 3 (20%) patients. 8 (53.3%) patients in pool A and 7 continued to show relief of mouth breathing, snoring,
(46.7%) patients in Pool B still had adenoid facies. There URTI and ASOM, while 7 (46.7%) patients still had
was no significant difference between the groups as per general facial features of the adenoid hypertrophy
Chi-Square test (p>0.05). (adenoid facies). On contrary in Pool A still patients were
Post-operatively on Day 7, results were similar showing symptoms like mouth breathing (20%), snoring
to that of Day 2 apart from few differences as shown in (20%), URTI (6.7%), ASOM (6.7%), adenoid facies
the table. There was no significant difference between (53.3%). There was no significant difference between the
the groups as per Chi-Square test (p>0.05). groups as per Chi-Square test (p>0.05).

2022
On post-operative Day 15,results were similar to

Year
that of post op day 7 only difference was in pool A, 6

Table 5: Distribution of patients according to Post-operative Symptoms on Day 2, day 7, day 15, day 30 17

J ) Volume XXII Issue II Version I

Post-operative Symptoms on Pool A Pool B
p value
Day 2 N % N %

Mouth Breathing 5 33.3% 2 13.33%

Snoring 3 20% 2 13.33%

URTI 3 20% 0 - >0.05

ASOM 0 - 0 -

Global Journal of Medical Research ( D

Adenoid facies 8 53.3% 7 46.7%

IV. Discussion and a 40° microdebrider blade through the mouth to

remove the adenoid and they realized that the limitation
Adenoidectomy pioneered in the 19th century of mobility of instruments through the nasal cavity could
by Hans Wilhelm Meyer, the procedure has radically be overcome with this approach [15]. Anand et al. in
evolved over the last century [11]. And with the advent 2014 suggested that this difficulty of maneuvering the
of endoscopes, surgeries in the nasal cavities have instruments can be overcome by passing the
become much safer as they provide precise a traumatic endoscope through one nostril and straight blade
dissection with lesser complications and faster microdebrider through the other [16].
postoperative healing [12] [13]. Along with many Even though both endoscopic assisted
advantages there exist minor disadvantages of EAMA microdebrider adenoidectomy (EAMA) and endoscopic
and EACA like the need to have a complete set of assisted coblation adenoidectomy (EACA) offer similar
endoscopicunit, microdebrider unit and coblator unit advantages over the older curettage technique, there
which includes setup and maintenance cost along with exist subtle differences between the two which set them
that there is also longer learning curve as it requires skill apart. This present study focusses to compare these
and expertise to operate these units in coherence[14] two adenoidectomy procedures based on different
Yanagisawa and Weaver in 1997 used an parameters as stated before.
endoscope along with a microdebrider through a In this study, males outnumbered females, Pool
transnasal approach and concluded that they had a A constituted of 53.3% male and 46.7% female patients
completeness of clearance of adenoid with significantly while Pool B had 60% male and 40% female patients.
lesser complications [13]. Costantini et al. in 2008, had Majority of the patients i.e., 40%in Pool A were in the
used a 70° endoscope with video attachment introduced age group of 9-12 years followed by 33.3% in the age

© 2022 Global Journals

 Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

group of 5-8 years and 26.7% in the age group of 13-15 demonstrated poor–average surgical field. The
years. The mean age of the patients in Pool A was 10.20 microdebrider group reported poor–average surgical
± 3.14 years. Majority of the patients i.e., 53.3% in Pool field in 37 cases while 33 cases showed good–excellent
B were in the age group of 9-12 years followed by 26.7% surgical field.
in the age group of 5-8 years and 20% in the age group Similarly mean VAS score for post operative
of 13-15 years. The mean age of the patients was 10.27 pain on Post op day 2 in pool A was 7.23+_
± 2.40 years. 0.51whereas in pool B was 7.48+_0.46. During post-
The difference in the groups was statistically not operative follow ups, VAS score for post op pain in pool
significant as per Student t-test (p>0.05). Our study was A on day 7th was 1.53+_0.26 and in pool B was
comparable to other studies carried out by Abo Elmagd 1.67+_0.35 which reduced to 0 for both the pools on
EA et al17 where the study evaluating micro-debrider- subsequent follow up days i.e., on post op day 15th and
assisted adenoidectomy and conventional curettage 30th. In both the techniques VAS Score for post
method found mean age of the patients was 7.27 ± operative pain were compared using Student t-test and
2022

2.36 years in group A (micro-debrider-assisted) and the result of the test were statistically not significant with
7.43 ± 2.87 years in Group B (conventional) and the p-value > 0.05. Jaskaran S et al19 prospective
Year

M/F ratio was nearly equal in both groups. randomised single blind study showed post-operative
In general, both the techniques were well 24 h mean pain score was 2.6 ± 0.99 and 7.14 ± 0.99
18 tolerated by the patients the major difference between in coblation and microdebrider group respectively. The
EAMA and EACA were found in terms of time taken for post-operative 72h mean pain score in coblation group
J ) Volume XXII Issue II Version I

surgery and blood loss during surgery. was 1.17±1.1 while in microdebrider group was
In the present study it was observed that the 4.08±1.42.
mean duration of surgery was significantly longer in Pool In the present study, Pre operatively in Pool A,
A compared to Pool B (25.07 ± 3.79 mins vs. 17.33 ± all patients showed symptom of mouth breathing i.e., 15
2.44 mins respectively)as per Student t-test (p<0.05) (100%), patients with snoring were 10 (66.7%), patients
This was also confirmed in study by Mularczyk C et al18 with recurrent Upper Respiratory Tract Infection (URTI)
which is a prospective, single-blinded, randomized and Acute Suppurative Otitis Media (ASOM) were8
controlled trial, showing mean time for coblation as 5.50 (53.3%), patients who had general facial features of
mins was significantly lower than mean time for adenoid facies were 7 (46.7%). In Pool B, 12 (80%)
microdebrider adenoidectomy that was 9.47 mins. patients each showed symptom of mouth breathing and
It is observed in our study that the mean snoring while 9 (60%) patients had URTI. 8 (53.3%)
intraoperative blood loss was significantly more in Pool patients had adenoid facies while 7 (46.7%) patients
had ASOM. There was no significant difference between
Global Journal of Medical Research ( D

A compared to Pool B as per Student t-test (51.27 ±

8.08 ml vs. 24.20 ± 4.74 ml p<0.05) and it is similar to the groups as per Chi-Square test (p>0.05). As per Abo
Jaskaran S et al19 prospective randomised single blind Elmagd EA et al17 study evaluating micro-debrider-
study which showed mean grade of intraoperative assisted adenoidectomy and conventional curettage
bleeding in coblator group was 1.4 ± 1.04 ml and in method showed most common presenting symptoms
microdebrider group was 3.5 ± 0.9ml. were nasal obstruction and sleep-disordered breathing.
In present study, nasal patency and post On post-operative evaluation on Day 2, 5
operative pain was studied with the help of mean VAS (33.3%) patients in Pool A and 2 (13.33%) patients in
score (visual analogue scale score). Although VAS score Pool B still showed symptom of mouth breathing while 3
is not a standardized test for nasal patency and pain (20%) patients in Pool A and 2 (13.33%) patients in Pool
evaluation, this study found that the results of this B still had snoring. URTI was only seen in Pool A that too
technique correlate well with the patients’ subjective also with 3 (20%) patients. 8 (53.3%) patients in pool A
sensation of nasal blockage and pain perception. and 7 (46.7%) patients in Pool B still had adenoid facies.
The mean pre-operative VAS score percentage There was no significant difference between the groups
for nasal patency in pool A was 84.60% whereas in pool as per Chi-Square test (p>0.05).
B was 92.4%. During post-operative follow up, VAS On post-operative Day 7 and 15, results were
score percentage for nasal patency in pool A on day 2nd similar only difference was in pool A, 6 patients (40%)
7th, 15th, 30th were 51%, 50%, 27.80% and 26.63% were having complaints of snoring and in pool B,
respectively, and in pool B on aforementioned days patients complaining of mouth breathing and snoring
were 92.4%, 42.30% 40%, 26.70% and 12.70% reduced to 1 that is 6.7%. There was no significant
respectively. The difference in VAS score percentage difference between the groups as per Chi-Square test
between pre-op and post-op values in both the groups (p>0.05).
was statistically significant as per ANOVA test (p<0.05). Post-operative Day 30, all patients in Pool B
Jaskaran S et al19 prospective randomised single blind continued to show relief of mouth breathing, snoring,
study reported coblation group had 69 cases with URTI and ASOM, while 7 (46.7%) patients still had
good–excellent surgical field while only 1 case general facial features of the adenoid hypertrophy

© 2022 Global Journals

Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

(adenoid facies). On contrary in Pool A still patients were method of nasal patency assessment like
showing symptoms like mouth breathing (20%), snoring rhinomanometry was not used due to cost restraints and
(20%), URTI (6.7%), ASOM (6.7%), adenoid facies instead subjective method of visual analog scale of 10-
(53.3%). There was no significant difference between the point scale was used for the same. A more elaborate
groups as per Chi-Square test (p>0.05). larger randomized studies with use of rhinomanometry
This is concordant to the studies of Singh S et would definitely be helpful to confirm or refute the same.
al20 which is a randomized study reported at the 3-
month follow-up, no residual disease was found in Acknowledgement
group II. However, in group I, 23 patients (77%) Not applicable.
presented with residual disease causing
nasopharyngeal symptoms and sleep-disordered Authorship contribution
breathing and residual disease were significantly higher All authors have read and approved the final
with the conventional technique compared to the manuscript. NKS and AK were responsible for
investigating and evaluating cases as per inclusion and

2022
endoscopic procedure.
exclusion criteria. All the cases were operated by SSC.
It was observed in our study that Pre operative
Final drafting of the article was done by NKS and AK

Year
grading of adenoid hypertrophy in Pool A, by nasal
under guidance of SSC. Entire research work was co-
endoscopy was as following, 5 (33.3%) patients was
ordinated and supervised by VDK. Conflict of interest 19
Grade 2 while it was Grade 3 and Grade 4 in 6 (40%)
The authors have no conflicts of interest to declare.
and 4 (26.7%) patients respectively. In Pool B, the grade

J ) Volume XXII Issue II Version I

of the adenoid hypertrophy in 3 (20%) patients was Ethics approval and consent to participate
Grade 2 while it was Grade 3 and Grade 4 in 5 (33.3%) Before starting the study, ethical clearance was
and 7 (46.7%) patients respectively. There was no taken from the institutional ethical committee.
significant difference between the groups as per Chi- Informed consent was duly taken from patients.
Square test (p>0.05). Consent for publication
When compared with Post Op Grading on Day Not applicable.
30 Grade 0 were seen in 5 (33.3%) patients in Pool A
and 9 (60%) patients in Pool B, grade 1 was seen in 4 References Références Referencias
(26.7%) patients in Pool A and 6 (40%) in Pool B. Grade 1. Stenner M, Rudack C. Diseases of the nose and
2 was only seen in pool A that too also in 6 (40%) paranasal sinuses in child. GMS Curr Top
patients. There was no significant difference between Otorhinolaryngol Head Neck Surg. 2014;13:Doc10
the groups as per Chi-Square test (p>0.05).
2. Bowers I, Shermetaro C. StatPearls [Internet].

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Jaskaran S et al19 prospective randomised StatPearls Publishing; Treasure Island (FL): 2021.
single blind study showed average adenoid grade in Adenoiditis.
coblation group was 3 ± 0.7 and in microdebrider group
3. Goeringer GC, Vidi ć B. The e mbryogenesis and
was 2.9 ± 0.6 respectively.
anatomy of Waldeyer's ring. Otolaryngol Clin North
Am. 1987; 20(2): 207-217.
V. Conclusion
4. Karanov J, Predrag M, Vladan S et al. [Cor
Even though the comfort and adequate training pulmonale caused by hypertrophic adenoid glands
of surgeon as well as cost affordability by the patients and tonsils: indications for tonsillectomy and
would determine the choice of technique to be used for adenoidectomy in a 2-year-old child]. 2000; 128.
endoscopic guided adenoidectomy over conventional 208-210.
method as both the procedures compared in our study 5. Pereira L, Monyror J, Almeida FT, Almeida FR,
do justice in the completeness of removal as well as in Guerra E, Flores-Mir C, Pachêco-Pereira C.
rate of complications still we can conclude that Prevalence of adenoid hypertrophy: A systematic
endoscopic assisted coblation adenoidectomy (EACA) review and meta-analysis. Sleep Med Rev. 2018
produce better results in treatment of adenoid Apr; 38: 101-112. [PubMed]
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this study was that different causes of adenoid Saturno TH, Prates MC, Gagliardi TB, Carenzi LR,
hypertrophy were not taken into consideration and Massuda ET, Hyppolito MA, Valera FC, Arruda E,
adenoid hypertrophy with associated symptoms not Anselmo-Lima WT. The pathogens profile in children
responding to medical line of management between the with otitis media with effusion and adenoid
age group of 5 to 15 years were included in this study. hypertrophy. PLoS One. 2017; 12(2):e0171049.
Another limitation of this study was that objective [PMC free article] [PubMed]

© 2022 Global Journals

 Comparative Study between Endoscopic Assisted Microdebrider Adenoidectomy (EAMA) and Endoscopic Assisted Coblation
Adenoidectomy (EACA): Analyzing the Intraoperative Parameters & Post-Operative Recovery

8. Regmi D, Mathur NN, Bhattarai M. Rigid endoscopic Conventional Adenoidectomy: A Randomized

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10. Cassano P, Gelardi M, Cassano M, Fiorella ML,
Fiorella R. Adenoid tissue rhinopharyngeal
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findings: a novel approach to therapeutic
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management. Int J PediatrOtorhinolaryngol. 2003;

67(12): 1303–9. – PubMed
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11. Datta R, Singh VP, Deshpal. Conventional versus

endoscopic powered adenoidectomy: A
20 comparative study. Med J Armed Forces India.
2009; 65(4): 308-12. doi: 10.1016/S0377- 1237(09)
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80089-0
12. Anil S Harugop,1 Samanvaya Soni,1 Tejaswini J
S1Efficacy and Safety of Microdebrider Assisted
Adenoidectomy over Conventional Adenoidectomy
Bengal Journal of Otolaryngology and Head Neck
Surgery Vol. 28 No. 1 April, 2020
13. Yanagisawa E, Weaver EM. Endoscopic
adenoidectomy with the microdebrider. Ear Nose
Throat J. 1997; 76(2): 72-4
14. Shapiro NL, Bhattacharyya N. Cold Dissection
versus coblation-assisted adenotonsillectomy in
children. Laryngoscope 2007; 117(3): 406–410.
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15. Costantini F, Salamanca F, Amaina T, Zibordi F.

Videoendoscopic adenoidectomy with
microdebrider. Acta Otorhinolaryngol Ital OrganoUff
Della Soc Ital Otorinolaringol E ChirCerv-facc. 2008;
28(1): 26-9
16. Anand V, Sarin V, Singh B. Changing Trends in
Adenoidectomy. Indian J Otolaryngol Head Neck
Surg. 2014; 66(4): 375-80
17. Abo Elmagd EA, Khalifa MS, Abeskharoon BK et al.
Comparative study between conventional
adenoidectomy and adenoidectomy using micro-
debrider. Egypt J Otolaryngol. 2021; 37: 56.
18. Mularczyk C, Walner DL, Hamming KK. Coblation
versus microdebrider in pediatric adenoidectomy.
Int J PediatrOtorhinolaryngol. 2018;104:29-31
19. Jaskaran S, Bhardwaj B. “The Comparison between
Microdebrider Assisted Adenoidectomy and
Coblation Adenoidectomy: Analyzing the
Intraoperative Parameters and Post-operative
Recovery.” Indian journal of otolaryngology and
head and neck surgery: official publication of the
Association of Otolaryngologists of India 2020;
72(1): 59-65.
20. Singh S. Padiyar BV, Sharma N. Endoscopic-
Assisted Powered Adenoidectomy versus

© 2022 Global Journals

 Global Journal of Medical Research: J
Dentistry & Otolaryngology
Volume 22 Issue 2 Version 1.0 Year 2022
Type: Double Blind Peer Reviewed International Research Journal
Publisher: Global Journals
Online ISSN: 2249-4618 & Print ISSN: 0975-5888

Orthopantomogram as an Assessment Tool for Identifying

Growth Pattern– A Radiographic Study
By Dr. Sajin Sam, Dr. Prasanna Turuvekere Ramaiah, Dr. Madhusudhan. V,
Dr. Suhas Setty, Dr. Dakshina CK & Dr. Sangeetha RV
Abstract- Aim: Growth prediction is an estimation of alteration in speed and direction of growth.
The ability to predict growth patterns of mandible, maxilla and other craniofacial structures plays
an important role in improving the reliability of treatment planning and long term success of
orthodontic patients. Bjork suggested structural signs such as inclination of condylar head,
curvature of mandibular canal, shape of lower border of mandible, depth of antegonial notch,
etc. to find the direction of mandibular growth. The purpose of the present study is to evaluate
mandibular growth pattern using various Bjork structural signs on Orthopantomograms.
Material and Methods: An analytical study was done with 84 pretreatment lateral cephalograms
(28 average, 28 horizontal, 28 vertical mandibular growth pattern) and 84 orthopantomograms
(28 average, 28 horizontal and 28 vertical mandibular growth pattern) of same patients.
Keywords: lateral cephalogram, OPG, mandibular curvature, gonial angle, inclination of condylar
head and depth of antegonial notch.
GJMR-J Classification: DDC Code: 616 LCC Code: RC78.7.D53

OrthopantomogramasanAssessmentToolforIdentifyingGrowthPatternARadiographicStudy

Strictly as per the compliance and regulations of:

© 2022. Dr. Sajin Sam, Dr. Prasanna Turuvekere Ramaiah, Dr. Madhusudhan. V, Dr. Suhas Setty, Dr. Dakshina CK & Dr.
Sangeetha RV. This research/review article is distributed under the terms of the Attribution-NonCommercial-NoDerivatives 4.0
International (CC BY-NC-ND 4.0). You must give appropriate credit to authors and reference this article if parts of the article are
reproduced in any manner. Applicable licensing terms are at https://creativecommons.org/licenses/by-nc-nd/4.0/.
 Orthopantomogram as an Assessment Tool for
Identifying Growth Pattern– A Radiographic
Study
Orthopantomogram as an Assessment Tool
α σ ρ Ѡ
Dr. Sajin Sam , Dr. Prasanna Turuvekere Ramaiah , Dr. Madhusudhan. V , Dr. Suhas Setty ,
¥ §
Dr. Dakshina CK & Dr. Sangeetha RV

2022
Abstract- Aim: Growth prediction is an estimation of alteration radiation exposure of the patient by taking an extra lateral

Year
in speed and direction of growth. The ability to predict growth cephalogram radiograph.
patterns of mandible, maxilla and other craniofacial structures Clinical Significance: Orthopantomogram can emerge as an
plays an important role in improving the reliability of treatment
21
assessment tool which can be cost effective and has reduced
planning and long term success of orthodontic patients. Bjork

J ) Volume XXII Issue II Version I

radiation exposure for diagnosing and prediction of
suggested structural signs such as inclination of condylar mandibular growth pattern in orthodontic cases.
head, curvature of mandibular canal, shape of lower border of Keywords: lateral cephalogram, OPG, mandibular
mandible, depth of antegonial notch, etc. to find the direction
curvature, gonial angle, inclination of condylar head and
of mandibular growth. The purpose of the present study is to
evaluate mandibular growth pattern using various Bjork depth of antegonial notch.
structural signs on Orthopantomograms.
I. Introduction
Material and Methods: An analytical study was done with 84

G
pretreatment lateral cephalograms (28 average, 28 horizontal, rowth is defined as the complete series of
28 vertical mandibular growth pattern) and 84 physiologic and anatomic changes taking place
orthopantomograms (28 average, 28 horizontal and 28 vertical
between the prenatal life and the close of
mandibular growth pattern) of same patients. Inclination of
condylar head, curvature of mandibular canal, depth of senility.1 Growth prediction is an assessment of
antegonial notch and gonial angles were analyzed both in alteration in the direction and speed of growth.2 Growth
lateral cephalogram and Orthopantomograms (both right and pattern of an individual can be influenced by various

Global Journal of Medical Research ( D

left side) to check for the growth pattern of an individual. factors such as genetics, environmental factors and
Results: Results showed significant difference in gonial angle nutritional supply. Evaluating the growth pattern
(129.820) and antegonial notch (1.97mm) when compared meticulously before initiating treatment improves the
among different growth patterns and also reliability of using reliability and stability of treatment in orthodontic
these parameters when analysed in OPG and lateral patients.3
cephalogram. Thus the correlation between The advent of lateral cephalogram has brought
orthopantomogram (OPG) and lateral cephalogram in drastic changes in diagnosis and treatment planning in
evaluating mandibular growth pattern was assessed using
Orthodontics. It became an important tool in clinical and
various parameters and its reliability is proven.
research domains to assess the underlying skeletal
Conclusion: Orthopantomogram can also be used to analyse disproportions.4 Cephalometry permits the evaluation of
the growth pattern of an individual which will reduce the
the spatial relationships between cranial, dental and
surface structures. All the evaluations are done by
Corresponding Author α: Postgraduate student, Department of certain landmarks or points on the skull being used for
Orthodontics, Sri Siddhartha Dental College, Sri Siddhartha Academy of
Higher Education (SAHE), Tumkur, Karnataka. the quantitative analyses and measurements. There are
e-mail: [email protected] various methods and parameters which are used for
Author σ ρ: Professor, Department of Orthodontics, Sri Siddhartha predicting mandibular growth pattern using lateral
Dental College, Sri Siddhartha Academy of Higher Education (SAHE) cephalogram. Y-axis angle, SN-GoGn, Frankfort
Tumkur, Karnataka.
Author Ѡ: Head of the Department and Professor, Department of Oral
mandibular plane angle, Jarabak's ratio and Facial axis
Medicine and Radiology, Sri Siddhartha Dental College, Sri Siddhartha angle are most broadly adopted lateral cephalogram
Academy of Higher Education (SAHE), Tumkur, Karnataka. parameters for predicting mandibular growth pattern.3
Author ¥: Senior Lecturer, Department of Orthodontics, Sri Siddhartha Bjork suggested structural signs such as
Dental College, Sri Siddhartha Academy of Higher Education (SAHE),
Tumkur, Karnataka.
curvature of mandibular canal, inclination of condylar
Author §: Postgraduate student, Department of Orthodontics, Sri head, intermolar angle shape of lower border of
Siddhartha Dental College, Sri Siddhartha Academy of Higher mandible, depth of antegonial notch, lower anterior
Education (SAHE), Tumkur, Karnataka. facial height and interincisal angle to find the direction of

© 2022 Global Journals

 Orthopantomogram as an Assessment Tool for Identifying Growth Pattern– A Radiographic Study

mandibular growth.5 Davidovitch studied the association through the two points of greatest convexity on the
between Bjork structures and skeletal patterns, inferior border of mandible, either side of the notch.
suggesting that these characteristics can be used • Gonial angle (Go): angle formed by the base of the
radiographically to examine the growth trends.6 mandible and posterior border of ramus.
In everyday practice, an orthopantomogram is The selected radiographs was traced on 0.03
routinely utilized to provide a bilateral perspective and tracing paper, landmarks located, lines and angles were
adequate data on vertical measurements. The number drawn and the above mentioned variables were
of teeth present, caries, root resorption, ankylosis, measured. The values obtained from linear and angular
impacted teeth, and shape of the condyles, measurements on orthopantomogram and lateral
temporomandibular joints, sinuses, fractures, cysts, cephalogram were compared, later the correlation
alveolar bone levels, and tumors have all been studied between orthopantomogram (OPG) and lateral
using it. Several studies have concluded that cephalogram in evaluating mandibular growth pattern
orthopantomogram (OPG) can effectively assess ramus was assessed.
height and gonial angle as lateral cephalogram.4,7,8
2022

However, lateral cephalogram cannot be reliably used III. Statistical Analysis

Year

for measuring the right and left sides of cranial SPSS (Statistical Package for Social Sciences) version
structures individually. This is due to overlapping of both 20. (IBM SPASS statistics [IBM corp. released 2011]
22 the sides and interference of superimposed images. was used to perform the statistical analysis
The reliability of cephalometric measurements
J ) Volume XXII Issue II Version I

• Data collected from pretreatment radiographs was

when determined on OPG is still to be investigated.
entered in the excel spread sheet.
Thus, purpose of this study was to determine the
mandibular growth pattern using various parameters of • Descriptive statistics of the explanatory and
OPG. outcome variables was calculated by mean,
standard deviation for quantitative variables,
II. Material and Methodology frequency and proportions for qualitative variables.
• Inferential statistics like
An analytical study was designed in which 84 o ANOVA was applied to compare among the
pretreatment lateral cephalograms (28 average, 28 groups with post-hoc Bonferroni for pair-wise
horizontal, 28 vertical mandibular growth pattern) and 84 comparison of Orthopantomogram and Lateral
pretreatment orthopantomogram (28 average, 28 Cephalogram parameters.
horizontal and 28 vertical mandibular growth pattern) of o Paired sample t test was used to compare the
same patients were retrieved from the record room of difference between Orthopantomogram and
Global Journal of Medical Research ( D

Department of Orthodontics, Sri Siddhartha dental Lateral Cephalogram parameters.

college, Tumakuru. The study involved one key person o Pearson’s correlation to correlate the parameters
and one examiner. The key person collected the of lateral cephalogram and orthopantomogram
radiographs, did coding and appraised the examiner was computed.
regarding the parameters. The pretreatment
orthopantomograms and lateral cephalograms were • The level of significance was set at 5%
divided into three mandibular growth pattern based on IV. Results
SN-Go-Gn angle:
On assessing the mean mandibular plane angle
• Average (G1): 28-36 degrees (Average)
among horizontal, average and vertical, it was found
• Hypodivergent (G2): ≤26 degrees (Horizontal)
highest for vertical mandibular growth pattern. There
• Hyperdivergent (G3): ≥ 38 (Vertical)
was a statistically significant difference seen between all
Examiner was blinded regarding the study the three groups in pairwise post hoc analysis.
radiographs. The parameters measured to evaluate
mandibular growth pattern in the present study includes: a) Lateral Cephalogram
The Gonial angle for horizontal, average and
• Inclination of condylar head (ICH): angle between a vertical mandibular growth pattern in lateral
tangent to the condylar head and tangent to cephalogram was 122.82±5.03, 126.68±4.05,
posterior border of the ramus. 129.82±4.9 respectively. The P value obtained was 0.00
• Curvature of mandibular canal (CMC): angle and was statistically significant. The antegonial notch for
between a line parallel with the first centimeter of the horizontal, average and vertical mandibular growth
mandibular foramen and a line representing the pattern in lateral cephalogram was 1.38±0.87,
direction of mandibular canal closest to the mental 1.56±0.89, 1.97±1.01 respectively. The P value
foramen. obtained was 0.16 and was statistically non-significant.
• Anti gonial notch (AN): vertical distance from The curvature of mandibular canal for horizontal,
deepest part of notch concavity to a tangent average and vertical mandibular growth pattern in lateral

© 2022 Global Journals

 Orthopantomogram as an Assessment Tool for Identifying Growth Pattern– A Radiographic Study

cephalogram was 134.96±3.76, 136±3.17, 136±3.59 growth pattern in lateral cephalogram was 167.25±3.77,
respectively. The P value obtained was 0.61 and was 165.82±4.4, 166.68±3.28 respectively. The P value
statistically non-significant. The inclination of condylar obtained was 0.50 and was statistically non-significant.
head for horizontal, average and vertical mandibular (Table 1).
Table 1: Comparison of gonial angle, antegonial notch, curvature of mandibular canal and inclination of condylar
head among average, horizontal and vertical mandibular growth pattern in lateral cephalogram.

LATERAL CEPH Horizontal Average Vertical P value

0.00*
GONIAL ANGLE 122.82±2.03 126.68±4.05 129.82±4.9
Significant
0.16
AN 1.38±0.87 1.56±0.89 1.97±1.01
NS

CMC 134.96±3.76 136±3.17 136±3.59 0.61

2022
NS
ICH 167.25±3.77 165.82±4.4 166.68±3.28 0.50

Year
NS
Kruskal Wallis test; *Statistically significant, p<0.05, NS- not significant
23
The Gonial angle for horizontal, average and mandibular growth pattern in orthopantomogram was

J ) Volume XXII Issue II Version I

vertical mandibular growth pattern in orthopantomogram 135.95±3.89, 136.71±3.18, 158.96±114.81respectively.
was123.38±4.4, 127.59±3.4, 130.07±5.35 respectively. The P value obtained was 0.46 and was statistically non-
The P value obtained was 0.00 and was statistically significant. The inclination of condylar head for
significant. The antegonial notch for horizontal, average horizontal, average and vertical mandibular growth
and vertical mandibular growth pattern in pattern in orthopantomogram was 167±2.48,
orthopantomogram was 1.35±0.88, 1.39±0.84, 165.73±4.14, 165.16±9.48 respectively. The P value
1.70±0.94 respectively. The P value obtained was 0.04 obtained was 0.28 and was statistically non-significant.
and was statistically significant. The curvature of (Table 2)
mandibular canal for horizontal, average and vertical
Table 2: Comparison of gonial angle, antegonial notch, curvature of mandibular canal and inclination of condylar
head among average, horizontal and vertical mandibular growth pattern in orthopantomogram

OPG Horizontal Average Vertical P value

Global Journal of Medical Research ( D

0.00*
GONIAL ANGLE 123.38±4.4 127.59±3.4 130.07±5.35
Significant
0.04*
AN 1.35±0.88 1.39±0.84 1.70±0.94
Significant
0.46
CMC 135.95±3.89 136.71±3.18 158.96±114.81 NS
0.28
ICH 167±2.48 165.73±4.14 165.16±9.48
NS
Kruskal Wallis test; *Statistically significant, p<0.05, NS- not significant

V. Discusssion and measurements. Mandibular growth is primarily

related to Condylar growth, it differs in forward and
Facial growth and development are of major backward rotations.5 FMA, SN-GoGn, Y-axis angle,
concern to the clinician. The direction and amount of facial axis angle and Jarabak’s ratio are the widely used
growth will significantly modify the type of orthodontic parameters measured on lateral cephalogram to predict
treatment modality. The ability to predict growth patterns the growth pattern of mandible.3 However, the inherent
of maxilla, mandible and other craniofacial structures ambiguity of locating landmarks and surfaces on the x-
plays a major role in improving the reliability of treatment ray image as the image lacks hard edges, shadows and
planning and long term success of orthodontic well defined outlines are major drawbacks of lateral
patients.3 cephalogram technique. High radiation exposure and
After the introduction of cephalometric cost are important limitations of this technique.
radiography in 1931 by Broadbent, it has been used as Panoramic radiography provides information such as
a primary tool for Orthodontic diagnosis and treatment axial inclination of teeth, maturation phases and
planning.4All the evaluations are done by certain points comprehensive view of surrounding tissue. This
or landmarks on the skull for the quantitative analyses technique is used mainly because of its comparatively

© 2022 Global Journals

 Orthopantomogram as an Assessment Tool for Identifying Growth Pattern– A Radiographic Study

low radiation exposure, patient’s comfort and significant bone deposition under the gonial angle.5 The presence
amount of diagnostic information which is attained by of a deep mandibular antegonial notch is suggestive of
examining all the teeth and basal bone at once.4,9 reduced mandibular growth potential and a vertical
Measurements on panoramic radiographs have mandibular growth pattern when analyzed on lateral
been called into question because of different cephalogram.14,15 In the present study, antegonial notch
methodological errors that includes distortion and was highest for vertical growth pattern in lateral
magnification of images.4 cephalogram (1.97±1.01 degree) and OPG (1.70±0.94
Right and left side structures can be effortlessly degree). Statistically significant difference seen between
visualized individually using orthopantomogram, cluding horizontal and vertical groups when evaluated in OPG.
any overlapping or superimposing structures that helps Curvature of mandibular canal (CMC) reflects
in minimizing the methodological errors.4 The possible the initial shape of the mandible and curving of
application of OPG for evaluating angular and linear mandibular canal can differentiate horizontal and vertical
measurements is being investigated using different growth pattern. The mandibular canal and the
parameters. In order to validate OPG as an assessment trabaculae related to it can be considered as stationary
2022

tool for identifying growth pattern there should be more because they are not remodeled to the same amount as
Year

parameters for determining the direction of growth and the outer surface of jaw. The curvature of canal tends to
its reliability has to be checked.10 be more pronounced than the mandibular contour in
24 In this present study mandibular growth pattern vertical type of condylar growth that is in horizontal
was assessed with three angular and one linear growth pattern.5 Comparison of mean mandibular canal
J ) Volume XXII Issue II Version I

parameter measured on orthopantomogram. The curvature among three growth patterns in this study
pretreatment orthopantomograms and lateral head films showed highest value for vertical growth pattern
were categorized into three mandibular growth pattern (158.96±114 degree) in OPG. When measured on
based on SN-Go-Gn angle. The values obtained from lateral cephalogram, the mean curvature of mandibular
angular and linear measurements on canal was high for both average (136±3.17) and vertical
orthopantomogram and lateral cephalogram were (136±3.59) growth pattern but statistically no difference
compared. was found between all three groups.
In this study mandibular plane angle was Forward or backward inclination of the condylar
measured between SN-Go-Gn in lateral cephalogram. head is a distinguishing sign that can predict the
Statistical significant difference was found in the vertical direction of growth. Forward inclination of condylar head
growth pattern (39.07±1.86 degree) with P<0.001 is presumed to be found in vertical growth pattern and
which is in line with the study done by Davidovitch et al backward inclination in horizontal growth pattern.5
where he found mandibular plane as a predictor to Davidovitch highlighted that when there are changes in
Global Journal of Medical Research ( D

check for the divergence pattern of an individual. remodelling in localized areas of condyle, there can be
Significant statistical difference was found between G1, differences in the direction and amount of condylar
G2 and G3 (P>0.05).6 growth.6 This variation in the condylar growth can lead to
Gonial angle represents the form of mandible2 slight differences in condylar inclination values in
and also plays an important role in predicting growth, different skeletal groups.5 In the present study the mean
profile changes and the condition of the lower anterior inclination of condylar head was highest for horizontal
teeth.11 Studies have evaluated the association of gonial growth mandibular growth pattern in OPG (165.73±4.4
angle with mandibular divergence and investigated the degree). The result obtained was contrast from the
integrity of gonial angle when measured on OPG and studies of Issacson et al, Herbert et al which suggested
lateral cephalogram.4,7,8,11 It was shown that gonial angle that condylar head is further forwardly inclined in
is related with mandibular divergence and can be hyperdivergent group and backwardly placed in
employed as a predictor of vertical growth pattern.12,13 hypodivergent group.16
These studies emphasized on the fact that gonial angle According to Bjork, not all the morphologic
can be assessed on OPG as precisely as lateral characteristics would be found in a particular individual,
cephalogram.4,7,8,11 The result obtained in this study but the greater the number of features present, the more
showed result in accordance with the earlier studies. accurate the prediction would be.5 There are various
Gonial angle was highest for vertical growth pattern in parameters which are used for predicting mandibular
OPG (130±5.35 degree) and lateral cephalogram growth pattern using lateral cephalogram. An alternative
(129±4.9 degree). There was a statistical difference method for predicting growth pattern using certain
between horizontal, average and vertical groups parameters on OPG has been investigated in this study.
(P>0.05). It can be deduced that OPG can be used to The accuracy of using OPG as an alternative tool for
determine gonial angle as accurately as lateral head lateral cephalogram was analyzed using more number
films. of parameters which makes the study more relevant.
Implant study has found that the prominence of Based on the results obtained from the present study it
deep antegonial notching is increased by the process of is clear that certain parameters like gonial angle and

© 2022 Global Journals

 Orthopantomogram as an Assessment Tool for Identifying Growth Pattern– A Radiographic Study

antegonial notch can be used for predicting different evaluation of extremes of skeletal morphology. Eur J
growth patterns and also the selected parameters can Orthod. 2016; 38: 555–62.
be evaluated using OPG. 7. Zangouei-Booshehri M, Aghili HA, Abasi M,
Further longitudinal studies with more samples Ezoddini-Ardakani F. Agreement between
has to be done to evaluate the other parameters which panoramic and lateral cephalometric radiographs
is useful to assess the mandibular growth pattern in for measuring the gonial angle. Iran J Radiol. 2012;
OPG. 9(4): 178-82.
8. Kundi, Ibadullah. Accuracy of Assessment of Gonial
VI. Conclusion angle by both hemispheres of panoramic images
and its comparison with lateral cephalometric
Evaluation of growth pattern carefully before the radiographic measurements. J Dent Health Oral
starting of treatment plays an important role in the long DisordTher. 2016; 4(4): 97-9.
term success and reducing the risk of lapse in an 9. Patil D. Association of panoramic radiograph and
individual. Various parameters should be used in a lateral cephalogram for evaluation of dento-facial

2022
guarded fashion to enhance the Orthodontist’s ability to characteristics- a cross sectional study. J Med
predict the growth pattern. Different craniofacial SciClin Res. 2019; 7(2).

Year
parameters have been successfully used in the 10. Bugaighis I, Ganeiber T. Assessment of the validity
prediction of growth pattern using lateral cephalogram, of orthopantomographs in the evaluation of 25
though the reliable parameters used for the evaluation mandibular steepness in Libya. J Orthod Sci. 2018;

J ) Volume XXII Issue II Version I

on growth pattern on Orthopantomogram is limited. The 7(1): 14.
results of present study evaluating Bjork’s indicators in 11. Mattila K, Altonen M, Haavikko K. Determination of
different skeletal pattern on OPG and lateral the gonial angle from the orthopantomogram. Angle
cephalogram showed that gonial angle and antegonial Orthod. 1977; 47(2): 107-10.
depth can be used as reliable parameters for growth 12. Mangla R, Singh N, Dua V, Padmanabhan P,
prediction. It can be concluded that certain parameters Khanna M. Evaluation of mandibular morphology in
like gonial angle and antegonial notch can be used for different facial types. ContempClin Dent. 2011; 2(3):
assessing mandibular growth pattern using OPG. 200-6.
Clinical Significance 13. Rubika J, Felicita AS, Sivambiga V. Gonial Angle as
Orthopantomogram which has been already in an Indicator for the Prediction of Growth Pattern.
use for diagnosing several other conditions with its cost World J Dent. 2015; 6(3): 161-3.
effectiveness can emerge as a useful assessment tool 14. Singer CP, Mamandras AH, Hunter WS. The depth of
which has reduced radiation exposure and convenient the mandibular antegonial notch as an indicator of

Global Journal of Medical Research ( D

for the patients in reducing the need for multiple mandibular growth potential. Am J Orthod
radiographs for diagnosing and prediction of Dentofacial Orthop. 1987; 91(2):117-24.
mandibular growth pattern in orthodontic cases. 15. Kolodziej RP, Southard TE, Southard KA, Casko JS,
Jakobsen JR. Evaluation of antegonial notch depth
References Références Referencias for growth prediction. Am J Orthod Dentofacial
Orthop. 2002; 121(4): 357‑63.
1. Meredith H. Toward a working concept of physical 16. Gowda RS, Raghunath N, Sahoo KC, Shivlinga BM.
growth. Am J Orthod Oral Surg. 1945; 31(9):440-58. Comparative study of mandibular morphology in
2. Turchetta BJ, Fishman LS, Subtelny J D. Facial patients with hypodivergent and hyperdivergent
growth prediction: A comparison of methodologies. growth patterns: a cephalometric study. Indian J
Am J Orthod. 2007; 132(4): 439-49. Orthod Soc. 2013; 47(4): 377-81.
3. Nathani R, Diagavane P, Shrivastav S, Kamble R,
Gupta D, Korde S. Evaluation of frontal sinus as a
growth predictor in horizontal, vertical, and average
growth pattern in children from 8 to 11 years: A
cephalometric study. J Indian Orthod Soc. 2016; 50:
101‑5.
4. Thailavathy V, Kumar S, Srinivasan D, Loganathan
D, Yamini J. Comparison of orthopantomogram and
lateral cephalogram for mandibular measurements.
J Pharm Bioall Sci. 2017; 9(5): 92-5.
5. Bjork A. Prediction of mandibular growth rotation.
Am J Orthod. 1969; 55(6): 585-99.
6. Davidovitch M, Eleftheriadi I, Kostaki A, Shpack N.
The use of Bjork’s indications of growth for

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 Orthopantomogram as an Assessment Tool for Identifying Growth Pattern– A Radiographic Study
2022 Year

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Global Journal of Medical Research ( D

© 2022 Global Journals

 Global Journal of Medical Research: J
Dentistry & Otolaryngology
Volume 22 Issue 2 Version 1.0 Year 2022
Type: Double Blind Peer Reviewed International Research Journal
Publisher: Global Journals
Online ISSN: 2249-4618 & Print ISSN: 0975-5888

Apert Syndrome: Orthodontic - Surgical Treatment

Alternatives and Execution Times. A Review of the Literature
By Yury Paola Giraldo–Barrero, Natalia Carrillo–Mendigaño,
Claudia Patricia Peña–Vega & Salomón Yezioro–Rubinsky
Universidad Nacional de Colombia
Abstract- Objective: Carry out a literature review about the orthodontic and surgical treatments of
Apert Syndrome, during the different stages of growth and development.
Methods: A search was made in the MedLine (PubMed), Science Direct, Scopus, and Wiley
Online Library databases with the combination of the following terms: Syndromic
craniosynostosis; Dental treatment; orthodontic treatment; Apert Syndrome; surgical treatment;
dental care. Types of the study included: Systematic and literature reviews, retrospective,
longitudinal, and cohort studies, series, and case reviews that were published between 1990-
2020 in Spanish or English; articles related to other syndromes and animal, or laboratory studies
were excluded. The articles were selected according to relevance and availability of full text;
repeated findings were eliminated; additionally, the snowball system was used in the selected
articles; the quality of the evidence was evaluated using the GRADE system.
Keywords: apert syndrome; orthodontic treatment; surgical procedures; dental care.
GJMR-J Classification: DDC Code: 617 LCC Code: RK1

ApertSyndromeOrthodonticSurgicalTreatmentAlternativesandExecutionTimesAReviewoftheLiterature
Strictly as per the compliance and regulations of:

© 2022. Yury Paola Giraldo–Barrero, Natalia Carrillo–Mendigaño, Claudia Patricia Peña–Vega & Salomón Yezioro–Rubinsky. This
research/review article is distributed under the terms of the Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-
NC-ND 4.0). You must give appropriate credit to authors and reference this article if parts of the article are reproduced in any
manner. Applicable licensing terms are at https://creativecommons.org/licenses/by-nc-nd/4.0/.
 Apert Syndrome: Orthodontic - Surgical
Treatment Alternatives and Execution Times. A
Review of the Literature
Síndrome De Apert: Alternativas De Tratamiento Ortodóntico - Quirúrgico Y
Tiempos De Ejecución. Una Revisión De La Literatura
Yury Paola Giraldo–Barrero α, Natalia Carrillo–Mendigaño σ, Claudia Patricia Peña–Vega ρ
& Salomón Yezioro–Rubinsky Ѡ

2022 Year
Resumen- Objetivo: Realizar una revisión de la literatura Palabras clave: síndrome de apert; tratamiento
acerca de los tratamientos ortodónticos y quirúrgicos del ortodóntico; procedimiento quirúrgico; atención
síndrome de Apert durante las diferentes etapas de
27
odontológica.
crecimiento y desarrollo.

J ) Volume XXII Issue II Version I

Abstract- Objective: Carry out a literature review about the
Métodos: Se llevó a cabouna búsqueda en las bases de datos orthodontic and surgical treatments of Apert Syndrome, during
MedLine (PubMed), Science Direct, Scopus y Wiley Online the different stages of growth and development.
Library con la combinación de los siguientes términos:
Methods: A search was made in the MedLine (PubMed),
Syndromiccraniosynostosis, Dental treatment, orthodontic
Science Direct, Scopus, and Wiley Online Library databases
treatment, Apert Syndrome, surgical treatment, dental care. Se
with the combination of the following terms: Syndromic
incluyeronrevisiones sistemáticas y de literatura, estudios
craniosynostosis; Dental treatment; orthodontic treatment;
retrospectivos, longitudinales y de cohorte, series y revisiones
Apert Syndrome; surgical treatment; dental care. Types of the
de caso publicados entre 1990 y 2020 en español o inglés; se
study included: Systematic and literature reviews,
excluyeron artículos relacionados con otros síndromes, así
retrospective, longitudinal, and cohort studies, series, and
como estudios en animales. Los artículos fueron
case reviews that were published between 1990-2020 in
seleccionados según su pertinencia y disponibilidad de texto
Spanish or English; articles related to other syndromes and
completo; hallazgos repetidos fueron eliminados;
animal, or laboratory studies were excluded. The articles were
adicionalmente, se utilizó el sistema bola de nieve en los
selected according to relevance and availability of full text;
artículos seleccionados; la calidad de la evidencia fue

Global Journal of Medical Research ( D

repeated findings were eliminated; additionally, the snowball
evaluada mediante el sistema GRADE.
system was used in the selected articles; the quality of the
Resultados: 34 artículos fueron incluidos (calidad alta: evidence was evaluated using the GRADE system.
2,moderada: 1, baja: 19 ymuy baja: 12). Entre estos, se
Results: 34 articles were included (High Quality: 2; Moderate:
identificaron discusiones relacionadas con la etapa de
1; Low: 19; Very Low: 12). Controversies were found related to
crecimiento a la que se recomienda realizar los
the stage of growth to which it is recommended to perform the
procedimientos quirúrgicos requeridos para minimizar sus
required surgical procedures to minimize the negative
impactos negativos. La mayoría de los artículos apoyan el
impacts. Most of the articles support therapeutic management
manejo terapéutico ejecutado por equipos multidisciplinarios.
by multidisciplinary teams.
Conclusiones: Un plan de tratamiento combinado de
Conclusions: A combined orthodontic and orthognathic
ortodoncia y cirugía ortognática se presentó como la mejor
surgery treatment plan was presented as the indicated option
opción para obtener los mejores resultados funcionales y
to obtain the best possible functional and aesthetic results for
estéticos para la población en cuestión. El momento
the population in question. The appropriate time during the
adecuado durante el crecimiento y desarrollo de los
growth and development of individuals to implement each
individuos para implementar cada fase de tratamiento fue
treatment phase was decided by each multidisciplinary team.
decidido por cada equipo multidisciplinario.
Keywords: apert syndrome; orthodontic treatment;
Author α: Odontóloga.Universidad Nacional de Colombia. Bogotá, surgical procedures; dental care.
Colombia. e-mail: [email protected]
Author σ: Odontóloga. Magíster en Ciencias Biológicas. Profesora
Asociada, Facultad de Odontología. Universidad Nacional de I. Introducción

E
Colombia. Bogotá, Colombia. e-mail: [email protected]
Author ρ: Odontóloga.Especialista en Cirugía Oral y Maxilofacial. l síndrome de Apert es una anomalía congénita
Especialista en Patología Oral. Magíster en Educación. Profesora craneofacial de herencia autosómica dominante
Asociada, Directoradel Departamentode Salud Oral, Facultad de que se presenta en 1:65.000 casos de nacidos
Odontología. Universidad Nacional de Colombia. Bogotá, Colombia.
e-mail: [email protected]
vivos (1). Su etiología se asocia con una mutación en el
Author Ѡ: Odontólogo. Especialista en Ortodoncia. Profesor Titular, receptor 2 del factor de crecimiento de fibroblastos, la
Facultad de Odontología. Universidad Nacional de Colombia. Bogotá, cual se encuentra en el cromosoma 10q26 en dos
Colombia. e-mail: [email protected]

© 2022 Global Journals

 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

codones adyacentes que codifican para - Estudios que presenten el desenlace y

serina(755TCG) y prolina(758CCT) (2). consecuencia de la alternativa utilizada. Esto
Clínicamente, se caracteriza por presentar teniendo en cuenta recidiva, eficiencia y menor
afectaciones sistémicas, craneomaxilares y funcionales cantidad de intervenciones.
como enfermedades cardiovasculares, obstrucción de
c) Criterios de exclusión
vías respiratorias, sindactilia en ambas extremidades,
hidrocefalia, craneosinostosis(3), turribraquicefalia(4), - Se excluyeron artículos que específicamente
retrusión de la parte media de la cara, hipertelorismo y presentaran alternativas de tratamiento a otro
exoftalmia, así como alteraciones dentales y síndrome asociado con craneosinostosis u otra
oclusales(3). forma de craneosinostosis.
El marcado compromiso craneomaxilar, antes - Se excluyeron estudios en animales o de
mencionado, implica que para su manejo debe laboratorio.
disponerse de un equipo multidisciplinario que incluye, La selección de artículos se realizó en tres
entre otras especialidades, neurocirujanos, cirujanos fases (Figura 1):
2022

plásticos, cirujanos maxilofaciales y ortodoncistas. Los 1. Observación de los títulos de los artículos, en
Year

protocolos de manejo varían; mientras algunos autores relación con el objetivo de la revisión.
señalan que el avance del tercio medio facial es 2. Análisis del resumen del artículo, en
28 conveniente realizarlo de manera temprana,otros correspondencia con el objetivo y propósito de esta
argumentan quehacerlode esta formatiende a requerir revisión.
J ) Volume XXII Issue II Version I

procedimientos secundarios y algunas veces 3. Revisión y evaluación del artículo en su totalidad.

terciarios(5–7).
El estudio fue aprobado por el Comité de Ética
Es relevante determinar las consecuencias de
de la Facultad de Odontología de la Universidad
las alternativas terapéuticas reportadas en la literatura y
Nacional de Colombia (Resolución B. CIEFO-189-2020).
el momento de su implementación, poniendo a
disposición una herramienta que oriente a los III. Resultados
profesionales para decidir las alternativas de
tratamiento y el mejor periodo para ejecutarlas (8). El Fase 1: las búsquedas se efectuaron de acuerdo con
objetivo del presente trabajo esrealizar una revisión de combinaciones booleanas, para un total de 2.506
literatura acerca de los tratamientos ortodónticos y artículos.De estos, se excluyeron 535 por encontrarse
quirúrgicos del síndrome de Apert durante las diferentes repetidos.
etapas de crecimiento y desarrollo.
Fase 2: de 1.971 artículos de la fase 1, se escogieron
Global Journal of Medical Research ( D

II. Métodos 523 que guardaban relación con el objetivo de

estetrabajo.
a) Tipo de revisión: Revisión narrativa de la literatura Fase 3: de los 523 artículos de la fase 2 se
La búsqueda de artículos se efectuó en las seleccionaron106. Se descartaron 232,pues no
bases de datos MedLine (PubMed), Science Direct, aportaban de manera específica a la construcción de
Scopus y Wiley Online Library. Se utilizaron esta revisión y 185 porque no contaban con texto
combinaciones de los terminus MeSH Syndromic completo gratuito. Así, se leyeron 106 artículos en texto
craniosynostosis and Dental treatment, and orthodontic completo, de los cuales se excluyeron 80 por no tener
treatment y Apert Syndrome and orthodontic treatment, relación con el propósito de la revisión. Finalmente, se
and surgical treatment, and dental treatment, and dental escogieron 26 que sí cumplían los criterios de inclusión
care.Los tipos de estudio considerados fueron propuestos y se utilizó el método de bola de nieve. De
revisiones sistemáticas y de literatura, estudios ese modo, se realizó su revisión bibliográfica, lo que
retrospectivos, longitudinales y de cohorte, series y, por permitió encontrar ocho artículos adicionales.
último, revisiones de caso. El análisis de la calidad de la evidencia de los
b) Criterios de inclusión artículos seleccionados se ejecutó utilizando el sistema
- Artículos con fecha de publicación entre1990 y GRADE, mediante el cual se clasifica la calidad de la
2020 en idioma inglés o español. evidencia (9) (Ver Tabla1). Para ello, en primer lugar, se
- Estudios que relacionen la edad del paciente con toma como consideración inicial el diseño del estudio,
síndrome de Apert y las alternativas de tratamiento para posteriormente incrementar o disminuir la
implementadas. calificación según otras variables metodológicas y sus
- Estudios que involucren pacientes con síndrome de resultados. Dos de los autores crearon una matriz de
Apert y que hayan recibido tratamiento, sin evaluación basándose en esta metodología; en caso de
restricciones de edad. discrepancia, se procedió nuevamente a revisar el
- Estudios que enfoquen su tratamiento en el área de artículo por ambos autores hasta llegar a un acuerdo.
ortodoncia y cirugía oral y maxilofacial.

© 2022 Global Journals

 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

Búsqueda en bases de datos Artículos repetidos encontrados

Id (n=6814) en las diferentes bases de datos
en (n = 535)
tifi PubMed (n=752)
ca Science direct (n=3410)
ci Scopus (n = 73)
ón Wiley online library (n =
2579)

Fase 1: artículos elegidos por Artículos excluidos luego de

título lectura del resumen (n = 1448)
Fil
(n = 1971)

2022
tr
o

Year
tr
o
Artículos excluidos por no
Fase 2: artículos elegidos por obtener el texto completo o por 29
revisión del resumen (n = 523) irrelevancia para la revisión (n =

J ) Volume XXII Issue II Version I

417)

El
eg
ibi Artículos excluidos por no
lid tener relación con el objetivo
Fase 3: artículos leídos en texto de esta revisión (n = 80)
ad completo (n = 106)
tr
o

Global Journal of Medical Research ( D

In Artículos seleccionados (n =26)
cl
ui
do
s Artículos seleccionados a partir
de método de bola de nieve (n =
8)

Fuente: elaboración propia.

Figura 1: Diagrama de flujo de búsqueda y selección de artículos
Resultados estos pacientes, 14 en el tratamiento quirúrgico, 2 en el
Como resultado de la búsqueda fueron tratamiento ortodóntico y 9 en un tratamiento integrado
seleccionadas 2 revisiones sistemáticas, 5 estudios ortodóntico-quirúrgico (Ver Tabla 1).
retrospectivos, 1 estudio de cohorte retrospectivo, 9
revisiones de literatura, 1 estudio tipo encuesta, 8 series
de casos, 2 estudios de casos y controles, 1 estudio
retrospectivo longitudinal, dos estudios longitudinales,
dos reportes de caso y finalmente 1 estudio prospectivo
(Ver Tabla 1).
De los artículos obtenidos, 1 se enfoca en las
características anatómicas de la craneosinostosis, 5 en
las características clínicas del síndrome y el tratamiento
en odontología general, 3 en el desarrollo dental de

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 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

Tabla 1: Tipos de estudio, enfoque y calidad de la evidencia

Nivel de
Tipo de estudio Autor/año Enfoque calidad de la
evidencia
Revisión sistemática Lopez–Estudillo et al. 2017 Características clínicas y tratamiento
(10) odontológico Alta
Saltaji et al.2014 (11) Tratamiento quirúrgico
Estudio retrospectivo Kaloust et al.1997 (12) Desarrollo dental Moderada
Letra et al.2007 (13) Características clínicas y tratamiento
odontológico Baja
Allam et al.2011(14) Tratamiento quirúrgico
Woods et al.2015 (15) Desarrollo dental
Wery et al.2015 (16) Tratamiento quirúrgico Muy baja
2022

Estudio de cohorte Oberoi et al.2012 (17)

retrospectivo
Year

Revisión Vargevik et al.2012 (18) Tratamiento integrado

Fadda et al.2015 (19) Tratamiento quirúrgico
30 Vilan-Xavier et al.2008 (20) Características clínicas y tratamiento Baja
odontológico
J ) Volume XXII Issue II Version I

Hoyos et al.2014 (21)

Ferraro et al.1991(22) Tratamiento integrado
Prahl-Andersen 2005 (23) Tratamiento ortodóntico
Blount et al.2007(24) Características anatómicas de la
craneosinostosis Muy baja
Panchal et al.2003 (25) Tratamiento quirúrgico
Azoulay et al.2020(26) Tratamiento integrado
Estudio tipo encuesta Susami et al.2018 (27) Tratamiento ortodóntico
Series de casos Fearon et al.2013 (28) Tratamiento quirúrgico
Carpentier et al.2014 (29) Tratamiento integrado Baja
Posnick et al.1995 (30) Tratamiento quirúrgico
Dalben et al.2006 (31) Características clínicas y tratamiento
odontológico
Ko et al.2012 (32) Muy baja
Global Journal of Medical Research ( D

Laure et al.2015(33) Tratamiento quirúrgico

Ponniah et al.2008 (34)
Hohoff et al.2007(35) Tratamiento integrado
Estudio de casos y Khonsari et al.2016 (36)
controles Glass et al.2018 (37)
Tratamiento quirúrgico Baja
Estudio retrospectivo Shetye et al.(38)
longitudinal
Estudio longitudinal Reitsma et al.2014(39) Desarrollo dental
Meazzini et al.2012 (40) Tratamiento quirúrgico
Reporte de caso Shin et al.2020(41) Características clínicas y tratamiento
Muy baja
odontológico

Miyazaki 2013 (42)

Estudio prospectivo Kahnberg et al.2010 (43) Tratamiento integrado

Fuente: elaboración propia según Guía GRADE.

En síntesis, de acuerdo a López-Estudillo et Tratamientos reparativos: estos abarcanprocedimientos
al.(10), dos tipos de tratamiento se realizan en los de neurocirugía, cirugía plástica y maxilofacial, cirugía
pacientes con síndrome de Apert: correctiva de manos y pies, así como de tipopreventivo
Tratamientos de soporte: estos incluyenlos siguientes - restaurativos en odontopediatría y de ortodoncia.
especialistas: pediatra, otorrinolaringólogo, ortopedista,
neurólogo, psicólogo, fonoaudiólogo, cardiólogo
pediatra, oftalmólogo y médico internista.

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 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

a) Tratamiento quirúrgico del síndrome de Apert primero las mujeres, ya que en ellas cesa el crecimiento
Según Faddaet al.(19), el plan de tratamiento más rápido que en los hombres; de esta forma, la
quirúrgico en el síndrome de Apert se divide en tres capacidad de crecimiento óseo no estaría restringida
pasos: por la formación de cicatrices ni la intervención
Nacimiento – 2 años: quirúrgica como tal. Cuando este procedimiento
El tratamiento para la craneosinostosis implica quirúrgico se realiza de manera temprana se tiende a
una intervención quirúrgica que consiste en la formar una cicatriz, que a futuro podría requerir cirugías
expansión de la bóveda craneal. Las preocupaciones adicionales. Por otro lado, se ha observado que cuando
sobre el aumento de la presión intracraneal influyen en la cirugía se lleva a cabo tardíamente puede haber un
la decisión del momento y la estratificación de la riesgo de recidiva; por lo tanto, es necesario avanzar en
intervención quirúrgica. La expansión de esta bóveda se el conocimiento de técnicas quirúrgicas que brinden
puede lograr como un procedimiento en una o varias mayor estabilidad a largo plazo (23).
etapas. Hay defensores de cada técnica y ningún b) Tratamiento ortodóntico del síndrome de Apert

2022
enfoque individual ha demostrado ser superior a otros El tratamiento de ortodoncia, idealmente,
de una manerasignificativa. La mayoría de los autores consta de dos fases: la primera en dentición mixta

Year
prefiereuna descompresión anterior temprana con una (preferiblemente mixta tardía) y la segunda en dentición
craneotomía como procedimiento principal, seguida de permanente (18,27).
una expansión de la bóveda craneal posterior (24). Si 31
- Primera fase: preferiblemente entre los 8 a 9 años
hay alteraciones graves en el bulbo ocular, a nivel

J ) Volume XXII Issue II Version I

(27). Se realiza el movimiento de los dientes para la
respiratorio o cerebral, se realiza un primer
corrección del apiñamiento anterior, si existe, el
procedimiento quirúrgico de manera temprana.
manejo tanto de los dientes impactados, o su
Periodo de crecimiento (hasta los 12 años): erupción ectópica, como de espacios y la mejora
Cirugía de avance del tercio medio facial de la relación maxilomandibular. Esta se hace
El proceso de avance del tercio medio facial va utilizando aparatos fijos o removibles, para lo que
a consistir usualmente en: se suele usar comúnmente un expansor maxilar
rápido o lento, una máscara de protracción maxilar
- Bipartición facial y osteogénesis por distracción
o aparatos funcionales; la elección del aparato a
Este procedimiento consiste en la división del
utilizar será del ortodoncista encargado del caso.
hueso frontal del borde supraorbitario. Así, las órbitas y
Este tipo de procedimientos se deben planear en
la parte media de la cara se liberan de la base del
conjunto con el cirujano, debido a queel solo
cráneo mediante una osteotomía monobloque.
tratamiento con estos aparatos, sin el
Posteriormente, se extrae un fragmento óseo de forma

Global Journal of Medical Research ( D

acompañamiento quirúrgico, no tendrá los
triangular de la línea media del tercio medio de la cara.
resultados esperados, especialmente en casos muy
La base de este segmento triangular se encuentra por
severos; es decir, casos en los que la anomalía
encima de la órbita y el ápice se halla entre los dientes
afecta la función de forma grave y no pueden ser
incisivos superiores. Después de eliminar este
solucionados únicamente con tratamiento
segmento, es posible rotar las dos mitades de la cara
ortodóntico(18,27).
media una hacia la otra, lo que resulta en una reducción
de la distancia orbitariay, al mismo tiempo, permitela Es recomendable que el paciente tenga acceso
nivelación del maxilar. Igualmente, se efectúa el avance a una valoración en ortodoncia mínimo a los 6 años,
del tercio medio por medio dedistracción preferiblemente antes, pues se hace necesario un
osteogénicaen un procedimiento llamado bipartición estudio adecuado sobre la edad en la que es más
por distracción. Esto con el fin de normalizar la relación conveniente hacer una expansión maxilar, que debe ser
entre el borde orbitario y el globo ocular, además de consultada a su vez con el cirujano. Al respecto, Prahl-
normalizar la posición del hueso cigomático, la nariz y el Andersen (23) recomienda que no debe ser realizada
maxilar en relación con la mandíbula (36). antes de la erupción de los caninos permanentes, para
evitar daños en el germen dental, por lo que solo a
Fin del crecimiento/edad adulta partir de los 9 años, o un poco después, es
- Cirugía LeFort II o III y osteotomía mandibular, para recomendable efectuar la expansión quirúrgica maxilar.
solucionar la maloclusión clase III y, en ocasiones, Esto como preparación para la futura distracción
mordida abierta. osteogénica en el plano sagital. Además, la expansión
- En algunos casos se utiliza la distracción maxilar temprana reduce, pero no elimina la ocurrencia
osteogénica. de impactación y apiñamiento dental, así como la
Cirugías tipo Le Fort II o Le Fort III necesidad de posteriores extracciones de los dientes
Las personas con síndrome de Apert permanentes maxilares (26). Por esa razón, no es
normalmente son intervenidas quirúrgicamente para la primordial realizarla de manera temprana, a menos de
fase final, a la edad de 17 o 18 años. Generalmente, que se evidencie la necesidad de hacerlo.

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 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

Si se realiza el avance de la mitad de la cara de necesaria la extracción de dientes y se requiere

manera temprana, se podría alterar el desarrollo de los cirugía ortognática en pacientes que tengan
dientes vecinos a los procedimientos quirúrgicos problemas esqueléticos severos (18,27), por lo que
requeridos así como su formación, lo que ocasionaría la también se evalúa la posibilidad de utilizar esta
necesidad de procedimientos adicionales(27). Este etapa como ortodoncia prequirúrgica (Ver tabla 2).
hallazgo suele encontrarse en las yemas dentarias de
los molares superiores, porque estas sufren lesiones IV. Discusión
causadas por el corte quirúrgico que debe ser El síndrome de Apert muestra características
ejecutado para el avance del tercio medio. Muchas clínicas y orofaciales particulares que afectan
veces esto provoca su erupción ectópica o anomalías especialmente el tercio medio facial; sin embargo,
en este diente, que según el estudio de Susami et también compromete otras áreas como el cráneo, el
al.(27) estuvieron presentes en el 58.3% de los casos cual se observa en forma de cono; además se exhiben
después de la cirugía de avance del tercio medio facial. manifestaciones oculares, orales y sindáctila de manos
Segunda fase: preferiblemente entre los 14 a 15 y pies (10). La literatura es consistente en estos
2022

-
años (27). En esta fase se hace el manejo de hallazgos, con alta posibilidad de presentarse en los
Year

impactaciones dentales con exposición quirúrgica y individuos afectados. Una característica que genera
tracción de dientes incluidos. Asimismo, se logra la controversia es el retraso en la maduración dental de
32 alineación completa de los dientes con aparatos estos individuos en comparación con la población sin
fijos tipo multibracket. En ocasiones se hace síndrome.
J ) Volume XXII Issue II Version I

Tabla 2: Resumen de etapas de tratamiento y recomendación según el autor

NIVEL DE CALIDAD
TRATAMIENTO EDAD AUTOR/AÑO DE LA EVIDENCIA RECOMENDACIÓN
SEGÚN GRADE (9)
Corrección de la De 3 a 6 Panchal et al.(25) Muy baja Aesta edad se previene una
craneosinostosis meses mayor progresión de la
(expansión craneal) deformidad y posibles
complicaciones asociadas con
aumento de la presión
intracraneal.
De los 6 a 12 Allam et al.(14) Baja En este periodo no se ha
meses demostrado que haya que
Global Journal of Medical Research ( D

realizarse una segunda

intervención por refusión sutural.
15 meses Fearon y Baja Podría evitarse posteriormente
Podner(28) la probabilidad de hacer una
intervención secundaria.
Corrección de la 13 meses Oberoi et al.(17) Baja Dependiendo de lo
sindáctila incapacitante que sea la
sindáctila, puede realizarse a
esta edad.
1 a 2 años Prahl-Andersen Baja Dependiendo de lo
(23) incapacitante que sea la
sindáctila, puede llevarse a
caboen estos rangos de edad.
Avance fronto- orbital 4 a 6 meses Allamet al.(14) Baja La intervención temprana puede
dar mejores resultados, para
evitar el proceso de refusión
sutural.
6 a 12 meses Oberoiet al.(17) Baja La intervención ligeramente
tardía puede dar mejores
resultados.

Tratamiento de 7 a 9 años Vargeviket al.(18) Baja Objetivos de tratamiento:

ortodoncia en corrección del apiñamiento
primera fase anterior, manejo de dientes
retenidos o erupción ectópica,
mantenimiento de espacio y
mejora de la relación
maxilomandibular. Se requiere

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Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

acompañamiento quirúrgico
para obtener los resultados
esperados.
Expansión maxilar 9 años Prahl- Baja Se recomienda no realizar antes
quirúrgicamente Andersen(23) de la erupción de los caninos
asistida permanentes, con el fin deevitar
daños del germen dental.
Avance del tercio 4 a 5 años Letra et al.(13) Baja Edad adecuada para hacereste
medio facial procedimiento, porque evita
necesidad de traqueotomía.
4 a 5 años Prahl- Baja El progreso y la sincronización
Andersen(23) con la distracción osteogénica
va a depender de la obstrucción
de la vía área que exista, el tipo
de maloclusión y el estado

2022
psicológico del paciente.
4 a 6 años Posnicket al.(30) Baja Se debe realizar de manera

Year
temprana esta cirugía si el
paciente sufre de apnea
33
obstructiva del sueño o
exorbitismo severo.

J ) Volume XXII Issue II Version I

4 a 6 años Hoyos et al.(21) Baja Edad adecuada para recibir
este procedimiento.
5 a 9 años Fearon y Baja Utilizando LeFort III con
Podner(28) bipartición facial, la intervención
posterior puede dar mejores
resultados.
6 años Susamiet al.(27) Baja Es deseable esperar a que este
erupcionado el primer molar,
pues se ha visto que esta
cirugía temprana puede
ocasionar daños en el germen
dental.
6 a 7 años Allamet al.(14) Baja Utilizando LeFort III con

Global Journal of Medical Research ( D

bipartición facial, la intervención
a esta edad puede dar mejores
resultados.
9 a 12 años Oberoiet al.(17) Baja Recomendado a esta edad si
las demandas funcionales no
han dictado una intervención
más temprana. Puede realizarse
un avance suficiente para la
cara de un adulto, evitando con
ello repeticiones del
procedimiento.
Tratamiento de 12 a 15 años Vargeviket al.(18) Baja Se haceel manejo de
ortodoncia en retenciones dentales con
segunda fase exposición quirúrgica y erupción
asistida por ortodoncia.
Ortodoncia prequirúrgica y
cirugía ortognática en pacientes
con problemas esqueléticos
severos.
LeFort III al final del 17 a 18 años Prahl- Baja La capacidad de crecimiento
crecimiento Andersen(23) óseo no estaría restringida por
la formación de cicatrices ni la
Osteogénesis por Koet al.(32) intervención quirúrgica como tal.
distracción Cuando la cirugía se realiza
Laureet al.(33) tardíamente puede haber un
Avance monobloque riesgo de recidiva.
frontofacial
Fuente: elaboración propia.

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 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

Considerando que tanto el diagnóstico como el largo plazo; todos estos estudios son de calidad baja
manejo clínico de pacientes con anomalías según la guía GRADE (9).
craneofaciales no constituyen procedimientos rutinarios Sin embargo, se puede concluir que, si la
para la odontología general, es relevante actualizar a severidad del caso lo permite, es conveniente esperar
esta y otras disciplinas. Esto a través de la revisión de la entre los 12 y 15 meses para realizar este
literatura disponible acerca de los aspectos principales procedimiento, con el fin de evitar que se dé un proceso
asociados con una adecuada atención ortodóntico- de refusión sutural y se tenga que llevar a cabouna
quirúrgica de los sujetos con síndrome de Apert. Al segunda intervención. De igual manera, el avance
efectuar el análisis de calidad de la evidencia, según el fronto-orbital, como destaca Allam et al. (14), debe
método de GRADE (9), la mayoría de artículos realizarse entre los 4 a 6 meses de edad; según Oberoi
resultaron de baja calidad, lo cual podría explicarse por et al. (17), entre los 6 a 12 meses, de acuerdo a su
la poca prevalencia que tiene el síndrome a nivel estudio de cohorte, en el cual evaluaron los resultados
mundial y, asimismo, a la dificultad de realizar estudios después de terminar el tratamiento integrado de 8
prospectivos y aleatorizados (Ver Tabla 1). pacientes con este síndrome. Hacerlo antes de los 6
2022

Los hallazgos en cuanto al desarrollo dental de meses, señalan Allam et al. (14), tuvo la ventaja de no
Year

estos pacientes es relevante, porque permite elegir la presentar refusión sutural, mientras que Oberoi et al.
alternativa de tratamiento más adecuada, aunque se (17) no especifican cuáles son las ventajas de llevarlo a
34 encuentran algunos contrastes. Kaloust et al.(12), en su cabo después de los 6 meses.
estudio retrospectivo, que examina las radiografías de Con relación a la corrección de la sindáctila,
J ) Volume XXII Issue II Version I

36 pacientes con este syndrome usando los métodos Oberoi et al. (17) y Prahl-Andersen (23), en su estudio
de Demirjian y Goldstein, concluyen que 31 de los 36 tipo revisión, en el que expusieron las controversias en
individuos tenían una edad dental inferior a su edad el manejo de las malformaciones craneofaciales,
cronológica. Por otro lado, Reitsma et al.(39), en su consideran que puede realizarse entre los 12 a 24
estudio longitudinal, en el que cotejaron los cambios en meses de edad; la priorización de este tratamiento
la morfología de la arcada dentaria entre28 pacientes dependerá de lo incapacitante que sea la sindáctila.
con síndrome de Apert y 457 controles, evidenciaron Entre mayor incapacidad le genere al paciente, más
que las dimensiones de la arcada dentaria eran rápido debe efectuarse la cirugía.
menores en pacientes con síndrome de Apert en Es relevante también que el paciente tenga
comparación con los sujetos de control. atención por parte de la especialidad de ortodoncia en
Los dos estudios defienden la idea de que hay la etapa de 7 a los 9 años, o si es necesario antes (18),
un retraso en el desarrollo dental en pacientes con este porque se pueden requerir procedimientos ortopédicos
síndrome, mientras que Woods et al.(15), en su estudio que ayuden a la protracción y expansión maxilar,
Global Journal of Medical Research ( D

retrospectivo, cuyo objetivo era cuantificar, mediante los haciendo uso de expansores maxilares rápidos y lentos.
métodos de Demirjian y Haavikko, el desarrollo dental Se emplean expansores rápidos en pacientes con
en 26 pacientes con síndrome de Apert en comparación potencial de crecimiento, antes del cierre de la sutura
con controles emparejados, concluyeron que no hay media palatina, y lentos cuando este potencial se ha
diferencia en el desarrollo dental entre ambos. No perdido, como mecanismos de anclaje de la máscara
obstante, siguiendo la guía GRADE (9), el estudio de facial. Con relación a la expansión maxilar, Prahl-
Kaloust et al.(12) es de nivel de calidad moderado y Andersen (23) recomienda realizarla solo después de la
está respaldado por el de Reitsma et al.(39), mientras erupción de caninos permanentes, para evitar daños en
que el de Woods et al.(15) es de calidad baja. Se debe el germen dental de este diente. Además, es importante
considerar que la metodología empleada por el estudio reconocer que será una expansión quirúrgicamente
de Kaloust et al.(12) es más rigurosa estadísticamente; asistida, ya que en la mayoría de los casos los
por su parte, la de Woods et al. (15) tiene limitaciones pacientes presentan un cierre temprano de otras
por el pequeño tamaño de la muestra empleada. suturas como la palatina (35), y el procedimiento
La mayor controversia entre los autores es la temprano de ortodoncia ayuda a mejorar la estética y la
relacionada con el tratamiento quirúrgico. Para la función del paciente, pero se hace necesaria una
corrección de la craneosinostosis se proponen tres cirugía posterior para obtener los resultados esperados.
edades. Primero, Panchal et al. (25) afirman que de 3 a Por otro lado, en esta etapa también se evaluará el
6 meses; pero es una revisión que no evidencia la desarrollo dental de estos pacientes, determinándose si
metodología utilizada; Fearon y Podner (28) plantean un existen agenesias u otras anomalías dentales, con el
tiempo de 6 a 12 meses, en su estudio de series de propósito de hacer una adecuada planeación a futuro
casos, que observó la evolución de 135 pacientes que lleve al paciente a una oclusión adecuada.
operados por un mismo cirujano durante 20 años; y, por Es necesario tener en cuenta que el tratamiento
último, Allam et al. (14) proponen 15 meses en su ortodóntico debe complementarse con las
estudio retrospectivo, en el cual registraron la evolución recomendaciones del equipo de cirugía a cargo,
de los procedimientos quirúrgicos de 35 pacientes a considerando la severidad del caso, pues suele ser

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 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

insuficiente el tratamiento ortopédico para corregir la opción de tratamiento sería esperar a que el paciente
alteración sagital maxilar. Por lo tanto, de común tenga la parte media de la cara lo suficientemente
acuerdo entre ambas especialidades, se definirán los avanzada para realizar este avance, como lo menciona
alcances de la expansión y la protracción maxilar, Oberoi et al. (17); pero si hay demandas funcionales
evitando que se vean comprometidos los que ameriten hacerlo de manera temprana, estas deben
procedimientos quirúrgicos posteriores, como el avance ser estimadas.
del tercio medio facial. La técnica quirúrgica más usada Existe acuerdo entre todos los autores respecto
para este procedimiento es la osteotomía Le Fort III a que, posteriormente, es importante iniciar la segunda
combinada con distracción osteogénica, debido a que fase del tratamiento de ortodoncia entre los 12 a 15
tiene ventajas como la eliminación de la necesidad de años (18). En esta fase se lleva a cabo la alineación
injertos óseos, la posibilidad de un mayor avance, la completa de los arcos maxilares, la exposición
reducción de requerir transfusiones y una estancia quirúrgica y la tracción de dientes incluidos y en
hospitalaria más corta (16). algunos casos, cuando se necesite cirugía ortognática,

2022
Letra et al.(13), en su estudio retrospectivo, que se requerirá ortodoncia prequirúrgica para hacer la
analizó las características intraorales de 36 pacientes posterior cirugía de LeFort III al final del crecimiento,

Year
con este síndrome, y Prahl-Andersen(23) están de entre los 17 y 18 años (23). Se debe considerar que si
acuerdo en que el avance quirúrgico maxilar debe se hace a una edad más temprana podría crearse una
realizarse entre los 4 a 5 años. Con ello se evita la cicatriz que requeriría una cirugía adicional, según 35
necesidad de una traqueotomía (13), lo que permite Prahl-Andersen(23).

J ) Volume XXII Issue II Version I

igualmente un mejor proceso de sincronización de la De la misma manera, es significativo considerar
distracción osteogénica (23), que es la técnica la estabilidad de este tipo de cirugía; Saltaji et al. (11),
quirúrgica con la que comúnmente se hace. Posnick et en su revisión sistemática, la cual evalúa la estabilidad,
al. (30), de acuerdo a su estudio de series de casos de a corto y largo plazo, de las estructuras óseas después
21 pacientes, en el cual observaron los cambios en las del avance medio facial mediante osteotomía Le Fort III
mediciones intracraneales antes y después de los convencional frente a Le Fort III con distracción
procedimientos quirúrgicos, y Hoyos et al. (21), en su osteogénica, establecieron que si la cirugía LeFort III se
revisión que no indica los métodos utilizados, reportan realiza en conjunto con distracción osteogénica el
que es mejor realizarlo entrelos 4 a 6 años; ellos resultado es estable a largo plazo.
consideran que si el paciente sufre de apnea En esta fase final también se puede hacer,
obstructiva o exorbitismo severo, postergarlo puede indican Ko et al. (32), de acuerdo con su estudio de
afectar su desarrollo normal (30). Por otro lado, Allam et serie de casos, en el que investigaron el efecto del
al. (14) y Susami y et al. (27), en su estudio tipo tratamiento y la estabilidad de la osteogénesis por

Global Journal of Medical Research ( D

encuesta, el cual analiza el tratamiento ortodóntico de distracción monobloque fronto-facial en 5 pacientes y
estos pacientes en 46 clínicas de Japón, afirman que Laure et al. (33), en su estudio de series de casos, que
debe llevarse a cabo a los 6 años; realizarlo antes observó el avance monobloque frontofacial con
afecta el germen dental del primer molar maxilar, lo que craneoplastia frontal en tres adolescentes con huesos
provoca anomalías dentales tanto de forma, tamaño y faciales adultos y deformaciones, una osteogénesis por
posición, o erupción ectópica e impacta de forma distracción o un avance monobloque frontofacial
negativa la oclusión del paciente (27). Fearon y Podner respectivamente. Se debe considerar, sin embargo, que
(28) recomiendan que debe hacerse entre los 5 a 9 ambos estudios fueron calificados de calidad muy baja
años y Oberoi et al. (17) de los 9 a 12 años, y solo si las según la guía GRADE (9), y al ser estos de series de
demandas funcionales no indican que tenga que casos no podemos sugerir cuál sería la mejor opción.
realizarse de manera temprana. Hacerlo a esta edad se Pese a esto, de acuerdo a lo observado en la revisión,
justifica, porque el desarrollo del tercio medio facial va a las técnicas que hacen uso de osteogénesis por
estar lo suficientemente avanzado, lo cual reduce la distracción han demostrado dar mejores resultados a
posibilidad de necesitar una segunda intervención largo plazo de acuerdo con Saltaji et al. (11) y Meazzini
quirúrgica. et al. (40), en su estudio longitudinal, en el cual
Frente a lo anterior, es relevante considerar lo analizaron los datos de 40 pacientes por 10 años que
mencionado por Shetye et al. (44), en su estudio fueron sometidos a osteogénesis por distracción.
retrospectivo longitudinal, que examinó la estabilidad y En conclusión, la presente revisión de literatura
el crecimiento esquelético del tercio medio facial a largo evidencia que un plan de tratamiento combinado de
plazo (10 años) después del avance de Le Fort III en ortodoncia y cirugía ortognática es la opción más
192 pacientes. Los investigadores indican que hay una indicada para obtener los mejores resultados
alta posibilidad de que esta intervención se tenga que funcionales y estéticos posibles para la población
repetir al terminar el crecimiento, porque la mandíbula afectada por el síndrome de Apert. El momento
continúa creciendo y eso hace que se dé una re- adecuado del crecimiento y desarrollo para recibir cada
expresión de un perfil de clase III esquelética. Otra fase del tratamiento será decisión del equipo

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 Apert Syndrome: Orthodontic - Surgical Treatment Alternatives and Execution Times. A Review of the
Literature

multidisciplinario tratante. A su vez, este trabajo refleja 8. Castro–Coyotl DM, Rosas–Huerta XO, Sánchez–
la necesidad de establecer estudios multicéntricos que Vázquez JJ, Díaz–Sánchez MI, Rodríguez–Peralta
generen publicaciones de alta evidencia científica, con JS, Tetitla–Munive JM et al. Guía de práctica clínica
protocolos de tratamiento consensuados que redunden para el diagnóstico, tratamiento y rehabilitación de
en mejores resultados de tratamiento para la población craneosinostosis no sindrómica en los 3 niveles de
afectada por el síndrome estudiado. atención. Cir Cir. 2017; 85(5): 401–410.
https://doi.org/10.1016/j.circir.2016.10.028
Agradecimientos 9. Broek JL, Akl EA, Alonso–Coello P, Lang D,
Jaeschke R, Williams JW, et al. Grading quality of
Agradecemos a la Facultad de Odontología de
evidence and strength of recommendations in
la Universidad Nacional.
clinical practice guidelines: Part 1 of 3. An overview
Contribución de los autores of the GRADE approach and grading quality of
Yury Paola Giraldo–Barrero, Natalia Carrillo– evidence about interventions. Allergy. 2009; 64(5):
Mendigaño, Claudia Patricia Peña–Vega y Salomón 669–677. https://doi.org/10.1111/j.1398-9995.2009.
2022

Yezioro–Rubinsky, colaboramos en la selección y 01973.x

evaluación de los artículos seleccionados tanto como
Year

10. López–Estudillo AS, Rosales-–Bérber MÁ, Ruiz–

en la construcción y revisión del documento y estamos Rodríguez S, Pozos–Guillén A, Noyola–Frías Á,
36 de acuerdo con la versión final. Garrocho–Rangel A. Dental approach for apert
Conflictos de interés syndrome in children: A systematic review. Med Oral
J ) Volume XXII Issue II Version I

Los autores y las autoras de este artículo Patol Oral Cir Bucal. 2017; 22(6): 660–668.
manifiestan no tener ningún conflicto de interés. https://dx.doi.org/10.4317%2Fmedoral.21628
11. Saltaji H, Altalibi M, Major MP, Al–Nuaimi MH,
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Designation
Get honored title of membership
Associates can use the honored title of membership. The “AMRC” is an honored
title which is accorded to a person’s name viz. Dr. John E. Hall, Ph.D., AMRC or
William Walldroff, M.S., AMRC.
Career Credibility Exclusive Reputation

Recognition on the Platform

Better visibility and citation
All the Associate members of AMRC get a badge of "Leading Member of Global Journals" on the Research
Community that distinguishes them from others. Additionally, the profile is also partially maintained by our team for
better visibility and citation.

Career Credibility Reputation

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VI
 Future Work
Get discounts on the future publications
Associates receive discounts on future publications with Global Journals up to 30%. Through our recommendation
programs, members also receive discounts on publications made with OARS affiliated organizations.

Career Financial

GJ Account
Unlimited forward of Emails
Associates get secure and fast GJ work emails with 5GB forward of emails that
they may use them as their primary email. For example,
john [AT] globaljournals [DOT] org.

Career Credibility Reputation

Premium Tools
Access to all the premium tools
To take future researches to the zenith, fellows receive access to almost all the
premium tools that Global Journals have to offer along with the partnership with
some of the best marketing leading tools out there.
Financial

Conferences & Events

Organize seminar/conference
Associates are authorized to organize symposium/seminar/conference on behalf of Global Journal Incorporation
(USA). They can also participate in the same organized by another institution as representative of Global Journal.
In both the cases, it is mandatory for him to discuss with us and obtain our consent. Additionally, they get free
research conferences (and others) alerts.

Career Credibility Financial

Early Invitations
Early invitations to all the symposiums, seminars, conferences
All associates receive the early invitations to all the symposiums, seminars, conferences and webinars hosted by
Global Journals in their subject.

Exclusive

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 Publishing Articles & Books
Earn 60% of sales proceeds
Associates can publish articles (limited) without any fees. Also, they can earn up to
30-40% of sales proceeds from the sale of reference/review
books/literature/publishing of research paper

Exclusive Financial

Reviewers
Get a remuneration of 15% of author fees
Associate members are eligible to join as a paid peer reviewer at Global Journals Incorporation (USA) and can get a
remuneration of 15% of author fees, taken from the author of a respective paper.

Financial

And Much More

Get access to scientific museums and observatories across the globe
All members get access to 2 selected scientific museums and observatories across the globe. All researches
published with Global Journals will be kept under deep archival facilities across regions for future protections and
disaster recovery. They get 5 GB free secure cloud access for storing research files.

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VIII
 Associate Fellow Research Group Basic

$4800 $6800 $12500.00 APC

lifetime designation lifetime designation organizational per article

Certificate, LoR and Momento Certificate, LoR and Certificates, LoRs and GJ Community Access
2 discounted publishing/year Momento Momentos
Gradation of Research Unlimited discounted Unlimited free
10 research contacts/day publishing/year publishing/year
1 GB Cloud Storage Gradation of Research Gradation of Research
GJ Community Access Unlimited research Unlimited research
contacts/day contacts/day
5 GB Cloud Storage Unlimited Cloud Storage
Online Presense Assistance Online Presense Assistance
GJ Community Access GJ Community Access

© Copyright by Global Journals | Guidelines Handbook

IX
Preferred Author Guidelines
We accept the manuscript submissions in any standard (generic) format.
We typeset manuscripts using advanced typesetting tools like Adobe In Design, CorelDraw, TeXnicCenter, and TeXStudio.
We usually recommend authors submit their research using any standard format they are comfortable with, and let Global
Journals do the rest.
Alternatively, you can download our basic template from https://globaljournals.org/Template
Authors should submit their complete paper/article, including text illustrations, graphics, conclusions, artwork, and tables.
Authors who are not able to submit manuscript using the form above can email the manuscript department at
[email protected] or get in touch with [email protected] if they wish to send the abstract before
submission.

Before and during Submission

Authors must ensure the information provided during the submission of a paper is authentic. Please go through the
following checklist before submitting:
1. Authors must go through the complete author guideline and understand and agree to Global Journals' ethics and code
of conduct, along with author responsibilities.
2. Authors must accept the privacy policy, terms, and conditions of Global Journals.
3. Ensure corresponding author’s email address and postal address are accurate and reachable.
4. Manuscript to be submitted must include keywords, an abstract, a paper title, co-author(s') names and details (email
address, name, phone number, and institution), figures and illustrations in vector format including appropriate
captions, tables, including titles and footnotes, a conclusion, results, acknowledgments and references.
5. Authors should submit paper in a ZIP archive if any supplementary files are required along with the paper.
6. Proper permissions must be acquired for the use of any copyrighted material.
7. Manuscript submitted must not have been submitted or published elsewhere and all authors must be aware of the
submission.
Declaration of Conflicts of Interest
It is required for authors to declare all financial, institutional, and personal relationships with other individuals and
organizations that could influence (bias) their research.

Policy on Plagiarism
Plagiarism is not acceptable in Global Journals submissions at all.
Plagiarized content will not be considered for publication. We reserve the right to inform authors’ institutions about
plagiarism detected either before or after publication. If plagiarism is identified, we will follow COPE guidelines:
Authors are solely responsible for all the plagiarism that is found. The author must not fabricate, falsify or plagiarize
existing research data. The following, if copied, will be considered plagiarism:
• Words (language)
• Ideas
• Findings
• Writings
• Diagrams
• Graphs
• Illustrations
• Lectures

© Copyright by Global Journals | Guidelines Handbook

X
• Printed material
• Graphic representations
• Computer programs
• Electronic material
• Any other original work

Authorship Policies
Global Journals follows the definition of authorship set up by the Open Association of Research Society, USA. According to
its guidelines, authorship criteria must be based on:
1. Substantial contributions to the conception and acquisition of data, analysis, and interpretation of findings.
2. Drafting the paper and revising it critically regarding important academic content.
3. Final approval of the version of the paper to be published.
Changes in Authorship
The corresponding author should mention the name and complete details of all co-authors during submission and in
manuscript. We support addition, rearrangement, manipulation, and deletions in authors list till the early view publication
of the journal. We expect that corresponding author will notify all co-authors of submission. We follow COPE guidelines for
changes in authorship.
Copyright
During submission of the manuscript, the author is confirming an exclusive license agreement with Global Journals which
gives Global Journals the authority to reproduce, reuse, and republish authors' research. We also believe in flexible
copyright terms where copyright may remain with authors/employers/institutions as well. Contact your editor after
acceptance to choose your copyright policy. You may follow this form for copyright transfers.
Appealing Decisions
Unless specified in the notification, the Editorial Board’s decision on publication of the paper is final and cannot be
appealed before making the major change in the manuscript.
Acknowledgments
Contributors to the research other than authors credited should be mentioned in Acknowledgments. The source of funding
for the research can be included. Suppliers of resources may be mentioned along with their addresses.
Declaration of funding sources
Global Journals is in partnership with various universities, laboratories, and other institutions worldwide in the research
domain. Authors are requested to disclose their source of funding during every stage of their research, such as making
analysis, performing laboratory operations, computing data, and using institutional resources, from writing an article to its
submission. This will also help authors to get reimbursements by requesting an open access publication letter from Global
Journals and submitting to the respective funding source.

Preparing your Manuscript

Authors can submit papers and articles in an acceptable file format: MS Word (doc, docx), LaTeX (.tex, .zip or .rar including
all of your files), Adobe PDF (.pdf), rich text format (.rtf), simple text document (.txt), Open Document Text (.odt), and
Apple Pages (.pages). Our professional layout editors will format the entire paper according to our official guidelines. This is
one of the highlights of publishing with Global Journals—authors should not be concerned about the formatting of their
paper. Global Journals accepts articles and manuscripts in every major language, be it Spanish, Chinese, Japanese,
Portuguese, Russian, French, German, Dutch, Italian, Greek, or any other national language, but the title, subtitle, and
abstract should be in English. This will facilitate indexing and the pre-peer review process.
The following is the official style and template developed for publication of a research paper. Authors are not required to
follow this style during the submission of the paper. It is just for reference purposes.

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Manuscript Style Instruction (Optional)
• Microsoft Word Document Setting Instructions.
• Font type of all text should be Swis721 Lt BT.
• Page size: 8.27" x 11'”, left margin: 0.65, right margin: 0.65, bottom margin: 0.75.
• Paper title should be in one column of font size 24.
• Author name in font size of 11 in one column.
• Abstract: font size 9 with the word “Abstract” in bold italics.
• Main text: font size 10 with two justified columns.
• Two columns with equal column width of 3.38 and spacing of 0.2.
• First character must be three lines drop-capped.
• The paragraph before spacing of 1 pt and after of 0 pt.
• Line spacing of 1 pt.
• Large images must be in one column.
• The names of first main headings (Heading 1) must be in Roman font, capital letters, and font size of 10.
• The names of second main headings (Heading 2) must not include numbers and must be in italics with a font size of 10.
Structure and Format of Manuscript
The recommended size of an original research paper is under 15,000 words and review papers under 7,000 words.
Research articles should be less than 10,000 words. Research papers are usually longer than review papers. Review papers
are reports of significant research (typically less than 7,000 words, including tables, figures, and references)
A research paper must include:
a) A title which should be relevant to the theme of the paper.
b) A summary, known as an abstract (less than 150 words), containing the major results and conclusions.
c) Up to 10 keywords that precisely identify the paper’s subject, purpose, and focus.
d) An introduction, giving fundamental background objectives.
e) Resources and techniques with sufficient complete experimental details (wherever possible by reference) to permit
repetition, sources of information must be given, and numerical methods must be specified by reference.
f) Results which should be presented concisely by well-designed tables and figures.
g) Suitable statistical data should also be given.
h) All data must have been gathered with attention to numerical detail in the planning stage.
Design has been recognized to be essential to experiments for a considerable time, and the editor has decided that any
paper that appears not to have adequate numerical treatments of the data will be returned unrefereed.
i) Discussion should cover implications and consequences and not just recapitulate the results; conclusions should also
be summarized.
j) There should be brief acknowledgments.
k) There ought to be references in the conventional format. Global Journals recommends APA format.
Authors should carefully consider the preparation of papers to ensure that they communicate effectively. Papers are much
more likely to be accepted if they are carefully designed and laid out, contain few or no errors, are summarizing, and follow
instructions. They will also be published with much fewer delays than those that require much technical and editorial
correction.
The Editorial Board reserves the right to make literary corrections and suggestions to improve brevity.

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Format Structure
It is necessary that authors take care in submitting a manuscript that is written in simple language and adheres to
published guidelines.
All manuscripts submitted to Global Journals should include:
Title
The title page must carry an informative title that reflects the content, a running title (less than 45 characters together with
spaces), names of the authors and co-authors, and the place(s) where the work was carried out.
Author details
The full postal address of any related author(s) must be specified.
Abstract
The abstract is the foundation of the research paper. It should be clear and concise and must contain the objective of the
paper and inferences drawn. It is advised to not include big mathematical equations or complicated jargon.
Many researchers searching for information online will use search engines such as Google, Yahoo or others. By optimizing
your paper for search engines, you will amplify the chance of someone finding it. In turn, this will make it more likely to be
viewed and cited in further works. Global Journals has compiled these guidelines to facilitate you to maximize the web-
friendliness of the most public part of your paper.
Keywords
A major lynchpin of research work for the writing of research papers is the keyword search, which one will employ to find
both library and internet resources. Up to eleven keywords or very brief phrases have to be given to help data retrieval,
mining, and indexing.
One must be persistent and creative in using keywords. An effective keyword search requires a strategy: planning of a list
of possible keywords and phrases to try.
Choice of the main keywords is the first tool of writing a research paper. Research paper writing is an art. Keyword search
should be as strategic as possible.
One should start brainstorming lists of potential keywords before even beginning searching. Think about the most
important concepts related to research work. Ask, “What words would a source have to include to be truly valuable in a
research paper?” Then consider synonyms for the important words.
It may take the discovery of only one important paper to steer in the right keyword direction because, in most databases,
the keywords under which a research paper is abstracted are listed with the paper.
Numerical Methods
Numerical methods used should be transparent and, where appropriate, supported by references.
Abbreviations
Authors must list all the abbreviations used in the paper at the end of the paper or in a separate table before using them.
Formulas and equations
Authors are advised to submit any mathematical equation using either MathJax, KaTeX, or LaTeX, or in a very high-quality
image.

Tables, Figures, and Figure Legends

Tables: Tables should be cautiously designed, uncrowned, and include only essential data. Each must have an Arabic
number, e.g., Table 4, a self-explanatory caption, and be on a separate sheet. Authors must submit tables in an editable
format and not as images. References to these tables (if any) must be mentioned accurately.

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Figures
Figures are supposed to be submitted as separate files. Always include a citation in the text for each figure using Arabic
numbers, e.g., Fig. 4. Artwork must be submitted online in vector electronic form or by emailing it.

Preparation of Eletronic Figures for Publication

Although low-quality images are sufficient for review purposes, print publication requires high-quality images to prevent
the final product being blurred or fuzzy. Submit (possibly by e-mail) EPS (line art) or TIFF (halftone/ photographs) files only.
MS PowerPoint and Word Graphics are unsuitable for printed pictures. Avoid using pixel-oriented software. Scans (TIFF
only) should have a resolution of at least 350 dpi (halftone) or 700 to 1100 dpi (line drawings). Please give the data
for figures in black and white or submit a Color Work Agreement form. EPS files must be saved with fonts embedded (and
with a TIFF preview, if possible).
For scanned images, the scanning resolution at final image size ought to be as follows to ensure good reproduction: line
art: >650 dpi; halftones (including gel photographs): >350 dpi; figures containing both halftone and line images: >650 dpi.
Color charges: Authors are advised to pay the full cost for the reproduction of their color artwork. Hence, please note that
if there is color artwork in your manuscript when it is accepted for publication, we would require you to complete and
return a Color Work Agreement form before your paper can be published. Also, you can email your editor to remove the
color fee after acceptance of the paper.
Tips for writing a good quality Medical Research Paper
1. Choosing the topic: In most cases, the topic is selected by the interests of the author, but it can also be suggested by the
guides. You can have several topics, and then judge which you are most comfortable with. This may be done by asking
several questions of yourself, like "Will I be able to carry out a search in this area? Will I find all necessary resources to
accomplish the search? Will I be able to find all information in this field area?" If the answer to this type of question is
"yes," then you ought to choose that topic. In most cases, you may have to conduct surveys and visit several places. Also,
you might have to do a lot of work to find all the rises and falls of the various data on that subject. Sometimes, detailed
information plays a vital role, instead of short information. Evaluators are human: The first thing to remember is that
evaluators are also human beings. They are not only meant for rejecting a paper. They are here to evaluate your paper. So
present your best aspect.
2. Think like evaluators: If you are in confusion or getting demotivated because your paper may not be accepted by the
evaluators, then think, and try to evaluate your paper like an evaluator. Try to understand what an evaluator wants in your
research paper, and you will automatically have your answer. Make blueprints of paper: The outline is the plan or
framework that will help you to arrange your thoughts. It will make your paper logical. But remember that all points of your
outline must be related to the topic you have chosen.
3. Ask your guides: If you are having any difficulty with your research, then do not hesitate to share your difficulty with
your guide (if you have one). They will surely help you out and resolve your doubts. If you can't clarify what exactly you
require for your work, then ask your supervisor to help you with an alternative. He or she might also provide you with a list
of essential readings.
4. Use of computer is recommended: As you are doing research in the field of medical research then this point is quite
obvious. Use right software: Always use good quality software packages. If you are not capable of judging good software,
then you can lose the quality of your paper unknowingly. There are various programs available to help you which you can
get through the internet.
5. Use the internet for help: An excellent start for your paper is using Google. It is a wondrous search engine, where you
can have your doubts resolved. You may also read some answers for the frequent question of how to write your research
paper or find a model research paper. You can download books from the internet. If you have all the required books, place
importance on reading, selecting, and analyzing the specified information. Then sketch out your research paper. Use big
pictures: You may use encyclopedias like Wikipedia to get pictures with the best resolution. At Global Journals, you should
strictly follow here.

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6. Bookmarks are useful: When you read any book or magazine, you generally use bookmarks, right? It is a good habit
which helps to not lose your continuity. You should always use bookmarks while searching on the internet also, which will
make your search easier.
7. Revise what you wrote: When you write anything, always read it, summarize it, and then finalize it.
8. Make every effort: Make every effort to mention what you are going to write in your paper. That means always have a
good start. Try to mention everything in the introduction—what is the need for a particular research paper. Polish your
work with good writing skills and always give an evaluator what he wants. Make backups: When you are going to do any
important thing like making a research paper, you should always have backup copies of it either on your computer or on
paper. This protects you from losing any portion of your important data.
9. Produce good diagrams of your own: Always try to include good charts or diagrams in your paper to improve quality.
Using several unnecessary diagrams will degrade the quality of your paper by creating a hodgepodge. So always try to
include diagrams which were made by you to improve the readability of your paper. Use of direct quotes: When you do
research relevant to literature, history, or current affairs, then use of quotes becomes essential, but if the study is relevant
to science, use of quotes is not preferable.
10. Use proper verb tense: Use proper verb tenses in your paper. Use past tense to present those events that have
happened. Use present tense to indicate events that are going on. Use future tense to indicate events that will happen in
the future. Use of wrong tenses will confuse the evaluator. Avoid sentences that are incomplete.
11. Pick a good study spot: Always try to pick a spot for your research which is quiet. Not every spot is good for studying.
12. Know what you know: Always try to know what you know by making objectives, otherwise you will be confused and
unable to achieve your target.
13. Use good grammar: Always use good grammar and words that will have a positive impact on the evaluator; use of
good vocabulary does not mean using tough words which the evaluator has to find in a dictionary. Do not fragment
sentences. Eliminate one-word sentences. Do not ever use a big word when a smaller one would suffice.
Verbs have to be in agreement with their subjects. In a research paper, do not start sentences with conjunctions or finish
them with prepositions. When writing formally, it is advisable to never split an infinitive because someone will (wrongly)
complain. Avoid clichés like a disease. Always shun irritating alliteration. Use language which is simple and straightforward.
Put together a neat summary.
14. Arrangement of information: Each section of the main body should start with an opening sentence, and there should
be a changeover at the end of the section. Give only valid and powerful arguments for your topic. You may also maintain
your arguments with records.
15. Never start at the last minute: Always allow enough time for research work. Leaving everything to the last minute will
degrade your paper and spoil your work.
16. Multitasking in research is not good: Doing several things at the same time is a bad habit in the case of research
activity. Research is an area where everything has a particular time slot. Divide your research work into parts, and do a
particular part in a particular time slot.
17. Never copy others' work: Never copy others' work and give it your name because if the evaluator has seen it anywhere,
you will be in trouble. Take proper rest and food: No matter how many hours you spend on your research activity, if you
are not taking care of your health, then all your efforts will have been in vain. For quality research, take proper rest and
food.
18. Go to seminars: Attend seminars if the topic is relevant to your research area. Utilize all your resources.
19. Refresh your mind after intervals: Try to give your mind a rest by listening to soft music or sleeping in intervals. This
will also improve your memory. Acquire colleagues: Always try to acquire colleagues. No matter how sharp you are, if you
acquire colleagues, they can give you ideas which will be helpful to your research.

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20. Think technically: Always think technically. If anything happens, search for its reasons, benefits, and demerits. Think
and then print: When you go to print your paper, check that tables are not split, headings are not detached from their
descriptions, and page sequence is maintained.
21. Adding unnecessary information: Do not add unnecessary information like "I have used MS Excel to draw graphs."
Irrelevant and inappropriate material is superfluous. Foreign terminology and phrases are not apropos. One should never
take a broad view. Analogy is like feathers on a snake. Use words properly, regardless of how others use them. Remove
quotations. Puns are for kids, not grunt readers. Never oversimplify: When adding material to your research paper, never
go for oversimplification; this will definitely irritate the evaluator. Be specific. Never use rhythmic redundancies.
Contractions shouldn't be used in a research paper. Comparisons are as terrible as clichés. Give up ampersands,
abbreviations, and so on. Remove commas that are not necessary. Parenthetical words should be between brackets or
commas. Understatement is always the best way to put forward earth-shaking thoughts. Give a detailed literary review.
22. Report concluded results: Use concluded results. From raw data, filter the results, and then conclude your studies
based on measurements and observations taken. An appropriate number of decimal places should be used. Parenthetical
remarks are prohibited here. Proofread carefully at the final stage. At the end, give an outline to your arguments. Spot
perspectives of further study of the subject. Justify your conclusion at the bottom sufficiently, which will probably include
examples.
23. Upon conclusion: Once you have concluded your research, the next most important step is to present your findings.
Presentation is extremely important as it is the definite medium though which your research is going to be in print for the
rest of the crowd. Care should be taken to categorize your thoughts well and present them in a logical and neat manner. A
good quality research paper format is essential because it serves to highlight your research paper and bring to light all
necessary aspects of your research.
Informal Guidelines of Research Paper Writing
Key points to remember:
• Submit all work in its final form.
• Write your paper in the form which is presented in the guidelines using the template.
• Please note the criteria peer reviewers will use for grading the final paper.
Final points:
One purpose of organizing a research paper is to let people interpret your efforts selectively. The journal requires the
following sections, submitted in the order listed, with each section starting on a new page:
The introduction: This will be compiled from reference matter and reflect the design processes or outline of basis that
directed you to make a study. As you carry out the process of study, the method and process section will be constructed
like that. The results segment will show related statistics in nearly sequential order and direct reviewers to similar
intellectual paths throughout the data that you gathered to carry out your study.
The discussion section:
This will provide understanding of the data and projections as to the implications of the results. The use of good quality
references throughout the paper will give the effort trustworthiness by representing an alertness to prior workings.
Writing a research paper is not an easy job, no matter how trouble-free the actual research or concept. Practice, excellent
preparation, and controlled record-keeping are the only means to make straightforward progression.
General style:
Specific editorial column necessities for compliance of a manuscript will always take over from directions in these general
guidelines.
To make a paper clear: Adhere to recommended page limits.

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Mistakes to avoid:
• Insertion of a title at the foot of a page with subsequent text on the next page.
• Separating a table, chart, or figure—confine each to a single page.
• Submitting a manuscript with pages out of sequence.
• In every section of your document, use standard writing style, including articles ("a" and "the").
• Keep paying attention to the topic of the paper.
• Use paragraphs to split each significant point (excluding the abstract).
• Align the primary line of each section.
• Present your points in sound order.
• Use present tense to report well-accepted matters.
• Use past tense to describe specific results.
• Do not use familiar wording; don't address the reviewer directly. Don't use slang or superlatives.
• Avoid use of extra pictures—include only those figures essential to presenting results.
Title page:
Choose a revealing title. It should be short and include the name(s) and address(es) of all authors. It should not have
acronyms or abbreviations or exceed two printed lines.
Abstract: This summary should be two hundred words or less. It should clearly and briefly explain the key findings reported
in the manuscript and must have precise statistics. It should not have acronyms or abbreviations. It should be logical in
itself. Do not cite references at this point.
An abstract is a brief, distinct paragraph summary of finished work or work in development. In a minute or less, a reviewer
can be taught the foundation behind the study, common approaches to the problem, relevant results, and significant
conclusions or new questions.
Write your summary when your paper is completed because how can you write the summary of anything which is not yet
written? Wealth of terminology is very essential in abstract. Use comprehensive sentences, and do not sacrifice readability
for brevity; you can maintain it succinctly by phrasing sentences so that they provide more than a lone rationale. The
author can at this moment go straight to shortening the outcome. Sum up the study with the subsequent elements in any
summary. Try to limit the initial two items to no more than one line each.
Reason for writing the article—theory, overall issue, purpose.
• Fundamental goal.
• To-the-point depiction of the research.
• Consequences, including definite statistics—if the consequences are quantitative in nature, account for this; results of
any numerical analysis should be reported. Significant conclusions or questions that emerge from the research.
Approach:
o Single section and succinct.
o An outline of the job done is always written in past tense.
o Concentrate on shortening results—limit background information to a verdict or two.
o Exact spelling, clarity of sentences and phrases, and appropriate reporting of quantities (proper units, important
statistics) are just as significant in an abstract as they are anywhere else.
Introduction:
The introduction should "introduce" the manuscript. The reviewer should be presented with sufficient background
information to be capable of comprehending and calculating the purpose of your study without having to refer to other
works. The basis for the study should be offered. Give the most important references, but avoid making a comprehensive
appraisal of the topic. Describe the problem visibly. If the problem is not acknowledged in a logical, reasonable way, the
reviewer will give no attention to your results. Speak in common terms about techniques used to explain the problem, if
needed, but do not present any particulars about the protocols here.

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The following approach can create a valuable beginning:
o Explain the value (significance) of the study.
o Defend the model—why did you employ this particular system or method? What is its compensation? Remark upon
its appropriateness from an abstract point of view as well as pointing out sensible reasons for using it.
o Present a justification. State your particular theory(-ies) or aim(s), and describe the logic that led you to choose
them.
o Briefly explain the study's tentative purpose and how it meets the declared objectives.
Approach:
Use past tense except for when referring to recognized facts. After all, the manuscript will be submitted after the entire job
is done. Sort out your thoughts; manufacture one key point for every section. If you make the four points listed above, you
will need at least four paragraphs. Present surrounding information only when it is necessary to support a situation. The
reviewer does not desire to read everything you know about a topic. Shape the theory specifically—do not take a broad
view.
As always, give awareness to spelling, simplicity, and correctness of sentences and phrases.
Procedures (methods and materials):
This part is supposed to be the easiest to carve if you have good skills. A soundly written procedures segment allows a
capable scientist to replicate your results. Present precise information about your supplies. The suppliers and clarity of
reagents can be helpful bits of information. Present methods in sequential order, but linked methodologies can be grouped
as a segment. Be concise when relating the protocols. Attempt to give the least amount of information that would permit
another capable scientist to replicate your outcome, but be cautious that vital information is integrated. The use of
subheadings is suggested and ought to be synchronized with the results section.
When a technique is used that has been well-described in another section, mention the specific item describing the way,
but draw the basic principle while stating the situation. The purpose is to show all particular resources and broad
procedures so that another person may use some or all of the methods in one more study or referee the scientific value of
your work. It is not to be a step-by-step report of the whole thing you did, nor is a methods section a set of orders.
Materials:
Materials may be reported in part of a section or else they may be recognized along with your measures.
Methods:
o Report the method and not the particulars of each process that engaged the same methodology.
o Describe the method entirely.
o To be succinct, present methods under headings dedicated to specific dealings or groups of measures.
o Simplify—detail how procedures were completed, not how they were performed on a particular day.
o If well-known procedures were used, account for the procedure by name, possibly with a reference, and that's all.
Approach:
It is embarrassing to use vigorous voice when documenting methods without using first person, which would focus the
reviewer's interest on the researcher rather than the job. As a result, when writing up the methods, most authors use third
person passive voice.
Use standard style in this and every other part of the paper—avoid familiar lists, and use full sentences.
What to keep away from:
o Resources and methods are not a set of information.
o Skip all descriptive information and surroundings—save it for the argument.
o Leave out information that is immaterial to a third party.

© Copyright by Global Journals | Guidelines Handbook

XVIII
Results:
The principle of a results segment is to present and demonstrate your conclusion. Create this part as entirely objective
details of the outcome, and save all understanding for the discussion.
The page length of this segment is set by the sum and types of data to be reported. Use statistics and tables, if suitable, to
present consequences most efficiently.
You must clearly differentiate material which would usually be incorporated in a study editorial from any unprocessed data
or additional appendix matter that would not be available. In fact, such matters should not be submitted at all except if
requested by the instructor.
Content:
o Sum up your conclusions in text and demonstrate them, if suitable, with figures and tables.
o In the manuscript, explain each of your consequences, and point the reader to remarks that are most appropriate.
o Present a background, such as by describing the question that was addressed by creation of an exacting study.
o Explain results of control experiments and give remarks that are not accessible in a prescribed figure or table, if
appropriate.
o Examine your data, then prepare the analyzed (transformed) data in the form of a figure (graph), table, or
manuscript.
What to stay away from:
o Do not discuss or infer your outcome, report surrounding information, or try to explain anything.
o Do not include raw data or intermediate calculations in a research manuscript.
o Do not present similar data more than once.
o A manuscript should complement any figures or tables, not duplicate information.
o Never confuse figures with tables—there is a difference.
Approach:
As always, use past tense when you submit your results, and put the whole thing in a reasonable order.
Put figures and tables, appropriately numbered, in order at the end of the report.
If you desire, you may place your figures and tables properly within the text of your results section.
Figures and tables:
If you put figures and tables at the end of some details, make certain that they are visibly distinguished from any attached
appendix materials, such as raw facts. Whatever the position, each table must be titled, numbered one after the other, and
include a heading. All figures and tables must be divided from the text.
Discussion:
The discussion is expected to be the trickiest segment to write. A lot of papers submitted to the journal are discarded
based on problems with the discussion. There is no rule for how long an argument should be.
Position your understanding of the outcome visibly to lead the reviewer through your conclusions, and then finish the
paper with a summing up of the implications of the study. The purpose here is to offer an understanding of your results
and support all of your conclusions, using facts from your research and generally accepted information, if suitable. The
implication of results should be fully described.
Infer your data in the conversation in suitable depth. This means that when you clarify an observable fact, you must explain
mechanisms that may account for the observation. If your results vary from your prospect, make clear why that may have
happened. If your results agree, then explain the theory that the proof supported. It is never suitable to just state that the
data approved the prospect, and let it drop at that. Make a decision as to whether each premise is supported or discarded
or if you cannot make a conclusion with assurance. Do not just dismiss a study or part of a study as "uncertain."

© Copyright by Global Journals | Guidelines Handbook

XIX
Research papers are not acknowledged if the work is imperfect. Draw what conclusions you can based upon the results
that you have, and take care of the study as a finished work.
o You may propose future guidelines, such as how an experiment might be personalized to accomplish a new idea.
o Give details of all of your remarks as much as possible, focusing on mechanisms.
o Make a decision as to whether the tentative design sufficiently addressed the theory and whether or not it was
correctly restricted. Try to present substitute explanations if they are sensible alternatives.
o One piece of research will not counter an overall question, so maintain the large picture in mind. Where do you go
next? The best studies unlock new avenues of study. What questions remain?
o Recommendations for detailed papers will offer supplementary suggestions.
Approach:
When you refer to information, differentiate data generated by your own studies from other available information. Present
work done by specific persons (including you) in past tense.
Describe generally acknowledged facts and main beliefs in present tense.

The Administration Rules

Administration Rules to Be Strictly Followed before Submitting Your Research Paper to Global Journals Inc.
Please read the following rules and regulations carefully before submitting your research paper to Global Journals Inc. to
avoid rejection.
Segment draft and final research paper: You have to strictly follow the template of a research paper, failing which your
paper may get rejected. You are expected to write each part of the paper wholly on your own. The peer reviewers need to
identify your own perspective of the concepts in your own terms. Please do not extract straight from any other source, and
do not rephrase someone else's analysis. Do not allow anyone else to proofread your manuscript.
Written material: You may discuss this with your guides and key sources. Do not copy anyone else's paper, even if this is
only imitation, otherwise it will be rejected on the grounds of plagiarism, which is illegal. Various methods to avoid
plagiarism are strictly applied by us to every paper, and, if found guilty, you may be blacklisted, which could affect your
career adversely. To guard yourself and others from possible illegal use, please do not permit anyone to use or even read
your paper and file.

© Copyright by Global Journals | Guidelines Handbook

XX
 CRITERION FOR GRADING A RESEARCH PAPER (COMPILATION)
BY GLOBAL JOURNALS

Please note that following table is only a Grading of "Paper Compilation" and not on "Performed/Stated Research" whose grading
solely depends on Individual Assigned Peer Reviewer and Editorial Board Member. These can be available only on request and after
decision of Paper. This report will be the property of Global Journals.

Topics Grades

A-B C-D E-F

Clear and concise with Unclear summary and no No specific data with ambiguous
appropriate content, Correct specific data, Incorrect form information
Abstract format. 200 words or below Above 200 words Above 250 words

Containing all background Unclear and confusing data, Out of place depth and content,
details with clear goal and appropriate format, grammar hazy format
appropriate details, flow and spelling errors with
specification, no grammar unorganized matter
Introduction and spelling mistake, well
organized sentence and
paragraph, reference cited

Clear and to the point with Difficult to comprehend with Incorrect and unorganized
well arranged paragraph, embarrassed text, too much structure with hazy meaning
Methods and precision and accuracy of explanation but completed
Procedures facts and figures, well
organized subheads

Well organized, Clear and Complete and embarrassed Irregular format with wrong facts
specific, Correct units with text, difficult to comprehend and figures
precision, correct data, well
Result structuring of paragraph, no
grammar and spelling
mistake

Well organized, meaningful Wordy, unclear conclusion, Conclusion is not cited,

specification, sound spurious unorganized, difficult to
conclusion, logical and comprehend
concise explanation, highly
Discussion structured paragraph
reference cited

Complete and correct Beside the point, Incomplete Wrong format and structuring
References format, well organized

© Copyright by Global Journals | Guidelines Handbook

XXI
 Index

Adenoid · 8, 9, 19, 20, 26

Advent · 9, 20, 29
Allocation · 8, 11

Cavitation · 2
Coagulated · 13
Concordant · 24
Curvature · 28, 29, 31, 32, 35

Debridement · 9, 11
Deduced · 34
Dissection · 20

Immersed · 1, 2
Inclination · 28, 30

Mandible · 28, 29, 30, 32, 33, 35

Mitigate · 2

Patency · 8, 11, 12, 13, 15, 16, 22, 24

Prominence · 34

Resection · 9, 12

Scarce · 2
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