Treatment Effects of Occipitomental

Anchorage Appliance of Maxillary

Protraction Combined with Chincup
Traction in Children with Class III
Malocclusion
Background/purpose
Little information related to the treatment effects of the occipitomental
anchorage (OMA) appliance of maxillary (Mx) protraction combined with
chincup traction is available. The aim of this study was to investigate the
treatment effects of the OMA orthopedic appliance on patients with Class
III malocclusion.

Methods
Pretreatment and post-treatment cephalometric records of 20
consecutively treated patients with Class III malocclusions were evaluated
and compared with a matched sample of untreated Class III control
subjects.

Results
The OMA appliance is effective for correcting skeletal Class III
malocclusion in growing children. The treatment effects of this orthopedic
appliance were considered to be from both skeletal and dentoalveolar
changes. The skeletal effects were mainly obtained by stimulating forward
growth of the Mx complex with negligible rotation of the Mx plane and
restraining forward advancement of the mandible (Mn) with backward and
downward rotation of the Mn plane. The observed dentoalveolar effects
were mostly due to the labial tipping movement of the Mx incisors.

Conclusion
Our results suggest that the OMA orthopedic appliance can correct the
mesial jaw relationship and negative incisal overjet. This appliance is
effective for correcting skeletal Class III malocclusion with both midface
deficiency and Mn prognathism in growing children.

A COMPARATIVE STUDY OF RADIOLOGICAL AND ANTROSCOPIC

FINDINGS IN THE LESIONS OF MAXILLARY SINUS
INTRODUCTION
Management of paranasal sinus disease has witnessed a
dramatic change in emphasis in the last two decades. It is
very difficult to determine the precise nature of the chronic
condition within the maxillary sinus, which in turn
compromises the treatment plan. Clinical symptoms and
signs are unhelpful with the onus falling on the
investigations currently available. Plain sinus X-rays have
poor sensitivity and low specificity (Jones, 1999).
Computerized Tomography (CT) also is not much better
in diagnosing rhinosinusitis. Many authors have found a
high rate of mucosal thickening and opacification on CT
in asymptomatic adults and children ( Manning et al, 1996
; Jones et al, 1997).
Antroscopy presents a possible solution to these problems.
It allows full inspection of the diseases in the sinuses.
Biopsies can be taken and specimens for culture and
sensitivity can be obtained. It also allows for photographic
documentaion.
There is difference of opinion regarding the correlation
between the endoscopic and radiological findings in the
previous studies on the subject (IlIum et al, 1972 ; Pfleidere
et al, 1986). Hence, the present study was carried out to
assess the relevance of different radiological techniques
in diagnosing maxillary sinus lesions and to determine the
degree of correlation between radiological and endoscopic
findings.
MATERIAL AND METHODS
Between November 1998 and December 1999, 84 patients
were selected from the outpatient department, suspected

of having maxillary sinus pathology. After a detailed history

and thorough clinical examination they were subjected to
standard protocol of investigations, which included
complete haemogram, X-ray paranasal sinuses
(occipitomental view) and CT scan nose and paranasal
sinuses (axial and coronal sections).
X-ray findings of 66 patients (103 sinuses) were noted
and classified as normal, slight thickening of mucosa ( <2
mm), moderate thickening of mucosa (>2 mm <half the
diameter of the sinuses), subtotal thickening of mucosa
(>half the diameter of the sinus), total opacification, cyst,
polyp and opacification with bony destruction. Mucosal
thickening was evaluated by measureing the distance
between the air mucosal interface and the inner bony
margins of the sinus. Isolated domed opacity was classified
as cyst while the mucosal thickening as polyp.
CT scan was done in 18 patients (30 sinuses) and findings
were noted and classified as normal mucosal thickening,
cyst, antral polyp, total opacification, and opacification
with bony destruction. CT attenuation values of maxillary
sinus pathologies were noted.
Only recent X-ray PNS/CT scan were taken up for the
study. The time duration between radiography and
antroscopy was not more than a week. Under local
anaesthesia, antroscopy was performed through the canine
fossa route. This was done as an OPD procedure in all
the patients and a total of 133 sinuses were examined
findings were noted and classifed as normal, congested
and oedematous mucosa, polypoidal mucosa, dry lusterless
mucosa with thickened bone on antral puncture, cyst,
1
Professor and Head, 2

Assiociate Professor, 3
Senior Resident, 4
Assistant Professor ( Statistics), Department of ENT and Head & Neck
Surgery, M. L. N. Medical College, Allahabad ( U.P.), India.10 A Comparative Study
of Radiological and Antroscopic Findings in the Lesions of Maxillary Sinus
Table I : Comparison of X-ray and Antroscopic findings in 103 maxillary sinuses
polyp, benign tumour, malignant tumour and miscellaneous
findings.
Radiological and antroscopic findings were then
compared. Positive predictive value or accuracy
(probability that an individual with positive test has the
disease) and the diagnostic accuracy (the percentage of
cases in which the test procedure correctly diagnosed) of
various radiological signs were evaluated.
OBSERVATIONS
The patients ranged in age from 10 to 63 years. Out of 84
patients, 60 were male while 24 were female. Majority of
patients presented with nasal blockage (61%) and postnasal
drip (51%). On X-ray examination, complete opacification
was the most common finding, being present in 44 sinuses
(42.7%). Thickening of mucosa was seen in 27 (26.2%),
cyst in 13 (12.7%), veiling in 9 (8.7%) and polyp in
7(6.8%) sinuses. On CT too, complete opacification was
the commonest finding (33.3%). Opacity with bony
destruction was seen in 5 (16.7%), mucosal thickening in
5 (16.7%) and cysts in 4 (13.3%).
Antroscopy was performed in all the cases. Bleeding
spoiled the view in 3% of the sinuses. These sinuses had
acutely inflamed mucosa. Bleeding was easily controlled
with irrigation and suction of the sinus with normal saline.
Antroscopy revealed polypoidal mucosal lining in 43 sinuses
(32.3%), congested and oedematous mucosa in 13 (9.8%),

dry and lusterless mucosa in 6 (4.5%), cysts in 21 (15.8%)

and polyps in 7 (5.3%). In 4 sinuses (3.1%) friable mass
was encountered, 3 were squamous cell carcinoma and 1
was papillary hyperplastic inflammation. In one sinus a
firm, smooth, round mass was seen which proved to be
a schwannoma. In 31% of the sinuses, mucoid or
mucopurulent exudates was encountered. In two known
Fig. I : Contrast enhanced C. T. Scan of the nose and paranasal sinuses,
axial view showing destruction of the posterior wall of left
maxillary sinus (black arrow) in case of antrochoanal polyp.
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1,
January - March 2004A Comparative Study of Radiological and Antroscopic
Findings in the Lesions of Maxillary Sinus 11
Table II : Comparison of antroscopic and C. T. findings in 30 maxillary sinuses.
* Indicate that C. T. Scan has given incorect information.
AC = Antrochoanal polyp Is = Inspissated secretions Sch = Schwannoma
SqCa=Squamous. cell carninoma
Table III : Attenuation values observed in C. T. scans
of maxillary sinus lesions.
diabetic patients antrum was found to be filled with thick
cheesy pus.
The X-ray findings were compared with antroscopic
findings as shown in Table No. 1. X-ray diagnosis was
incorrect in 49 sinuses (47.6%). The CT findings and
antroscopic findings were compared and are shown in
Table No. II. The CT diagnosis was incorrect in 3 sinuses
(10%).
The attenuation values as observed in CT scan were
compared with the antroscopic findings ( Table No. III).
Mucoid and mucopurulent secretion had value of -20 HU
to 20 HU while inspissated secretions had attenuation
values upto 121HU.
The reliability of radiological and antroscopic examination

was finally compared (Table No. IV). The percentage of

agreement between X-ray and antroscopy and between
Fig. II : Plain C. T. Scan nose and paranasal sinuses, axial view showing
hyperdense opacity ( AV : 104-121 HU) of right maxillary
sinus (white arrow) due to inspissated secretion.
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1,
January - March 200412 A Comparative Study of Radiological and Antroscopic
Findings in the Lesions of Maxillary Sinus
Table IV : Comparison of reliability of Antroscopy with X-ray and C. T. Scan
CT and antroscopy were found to be 52.4% and 90%
respectively. This difference of agreement was found to
be highly significant (p<0.001) by normal test of
significance.
The incidence of complication with antroscopy was very
low. Anaesthesia and swelling of face and cheek for 2 to
3 days was only complication seen (2.3%). Vasovagal
shock was not encountered in any case.
Besides diagnostic value, the sinus endoscopy served a
therapeutic function in a number of cases. All the cysts
seen during the study were decapped. Their contents were
sucked and the lining was completely removed. Lavage
was done of all the sinuses filled with purulent or
mucopurulent exudate. Biopsies were taken from 33 sinues
having cyst, polyp, growth or diseased sinus mucosa
with the help of special biopsy forceps and were sent for
histopathological examination.
DISCUSSION AND CONCLUSIONS
In our study various radiographic signs had wide variation
in the predictive as well as diagnositic efficacy.
Reduced translucency or veiling as a sign of diseased sinus
had a very poor positive predictive value (11.1%). Poor
radiographic techniques were found to be responsible for
it. Soft exposure as well as marked tilting of tube or the

head of the patient can result in veiling. Furthermore this

sign is subject to interobserver variation (Elwany et al,
1985).
Mucosal thickening was correctly predicted in 63% and
100% cases on X-ray and CT examination respectively.
On X-ray examination, false positivity increases if attention
is not paid to a narrow zygomatic recess, position of orbital
floor, and to the shadow of upper lip (Elwany et al, 1985;
Pfleiderer et al, 1986). These factors were seen in our
study too. Multiple cysts gave rise to a false picture of
thickening. Thick secretion sticking to the mucosal lining
can be another reason (Bailey, 1981). It was certainly in
one of our cases. CT examination was perfectly reliable
as far as mucosal thickening was concerned. However, a
previous work had found mucosal thickening as an
incidental findings on CT examination (Havas et al, 1988).
Total opacity on X-ray was taken as a sign of severe
polypoidal mucosal thickening or mucosal edema or an
antrochoanal polyp. IiIum et al (1972) comparing X-ray
examination and antroscopy had found polypoidal mucosa
in 25% and edematous mucosa in 58% of their cases with
total opacity while Pfleiderer et al (1986) had found these
findings in 58% and 34% of their cases respectively.
However, in our study we found these findings in only
34% and 18% of cases respectively giving a predictive
accuracy of 57% and diagnostic accuracy of 67%. Almost
23% of cases were found to be normal, poor radiographic
techniques being responsible for the false opacity. Multiple
cysts can show as total opacity as can a cyst or a polyp in
an overtilted occipitomental view. Thick bone of the sinus
can also show as opacity on X-ray (Baissouny et al, 1982)
and was so in 7% of our cases.

Total opacity on CT scan had a predictive accuracy of

100% but the same fell to 60% for opacity with destruction
of posterior wall which is considered to be pathognomic
of sinus malignancy (Silver et al, 1988). CT of one of
these cases is shown in fig. I. On antroscopy one proved
to be an antrochoanal polyp and the other to be a
schwannoma. The posterior wall was found to be intact
on palpation from inside in both the cases. This dehiscence
on CT was probably due to the effect of partial volume
averaging. In this a thin plate of bone at certain angle to
the X-ray beam will appear thicker that it should, an
averaging of attenuation value may mimic soft tissue
(Phelps, 1997).
The presence of a cyst or polyp has been considered to
be an excellent X-ray sign as far as the diagnostic and
predictive accuracies are considered ( Elwany et al, 1985).
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1,
January - March 2004A Comparative Study of Radiological and Antroscopic
Findings in the Lesions of Maxillary Sinus 13
This was so in the case of cyst for which the diagnostic
and predictive accuracies were 89% and 77% respectively.
In the case of polyp the predictive accuracy fell to 29%
as 4 cases showing as polyp on X-ray were really cyst,
false mucosal thickening leading to a wrong diagnosis.
Cysts were also an excellent sign on CT examination
(Predictive accuracy-75%, diagnositic accuracy - 97%)
but for a case in which a bleb of mucus masqueraded as
a cyst on CT examination. This had been observed
previously by Stammberger and Hawke (1993) also.
Attention values were not found to be useful in tissue
characterizatin. All pathologies had a wide variation in their
values. Our views are similar to those of Forbes et al
(1978) and Phleps (1997). Hyperdense opacity (AV : 104-

121 HU) was seen in the antrum of a patients having

ethmoidal polypi (Fig.II). Antroscopy revealed it to be
inspissated secretion, which confirmed the views of Som
(1991). According to him inspissated secretion as well as
fungal masses can have high attenuation values.
The correlation between X-ray and antroscopic diagnosis
was poor in our study (52.4%). Previous studies on the
subject have also shown poor correlation with IiIum et al
(1972) and Decreton and Clement (191) showing
correlation of 62% and 66% respectively while Pfleiderer
et al (1986) have shown a correlation of 44%. In the
present study X-ray examination produced false positive
and false negative findings of 44% and 4% respectively,
similar to respective figures of 35% and 9% found by
Fleiderer et al (1986).
CT had an excellent correlation of 90% with antroscopic
examination and certainly is better than X-ray examination
but its cost is still prohibitory to our patients.
It is concluded that antroscopy in the lesions of maxillary
sinus is certainly better than X-ray examination but its
cost is still prohibitory to our patients.
It is concluded that antroscopy in the lesions of maxillary
sinus is certainly better than radiographic examination
having not only diagnostic but therapeutic implication as
well.
REFERENCES
1. Jones N. S. (1999): Current concepts in management of peduatric
rhinosinusits. Journal of Laryngology & Otology 113 (1) : 1-9.
2. Manning S., Biavati M. J. and Philips D. L. (1996): Correlation
of clinical signs and symptoms to imaging findings in pediatric
patients. International Journal of Pediatric Otorhinolaryngology
37 : 65-74.

3. Jones N. S., Strobl A. and Holland I. (1997) : C. T. Findings in

100 patients with rhinosinustitis and 100 controls. Clinical
Otolaryngology 22 : 47-51.
4. IiIum P, Jepessen F., and Langenbeck E. (1972) : X-ray
examination of and sinoscopy in maxillary sinus disease. Acta
Otolaryngology 74 : 287-292.
5. Decreton S. J., Clement P. A. (1981) : Comparative study of
standard X-ray of the maxillary sinus and sinoscopy in children.
Rhinology 19 (3) : 155-159.
6. Pfleiderer A. G., Croft C. B. and Llyod G. A. S. (1986) :
Antroscopy : its place in the clinical practice. A comparison of
antroscopic findings with radiographic appearance of the
maxillary sinus. Clinical Otolaryngology 11 (6) : 455-461.
7. Stammberger, H and Hawke M. (1993): Essential of Endoscopic
sinus surgery Mosby -Year Book Inc.
8. Forbes W. S. T. C, Fawcitt R. A., Isherwood I., Webb R. and
Farrington T. (1978) : Computed tomography in the diagnosis
of diseases of the paranasal sinuses. Clinical Radiology 29 :
501-511.
9. Phleps, P. D. (1997) : Imaging and radiography. Scott Brown's
Otolaryngology. Butterworth-Heinemann 1/17 : 4-5.
10. Phleps P. D. (1997) : Radiology of nose and paranasal sinuses.
Scott Brown's Otolaryngology. Butterworth-Heinemann 4/3 :5.
11. Silver J., Baredes S. J. A., Blitzer A. and Hilal s. K. (1987) : the
opacified maxillary sinus : CT findings in chronic sinusitis and
malignant tumors. Radiology 163: 205-210.
12. Som P. M. (1991) : Sinonasal cavity. Head and Neck Surgery
Imaging. Ed. 2 St. Louis. Mosby-Year book : 51-276.
13. Bailey Q. R. (1981) : Chronic sinusitis in children. Journal of
Laryngology and Otology 95 : 55-60.
14. Bassiouny A., Newlands W. J., Ali H., and Zaki Y. (1982) :
Maxillary sinus hypoplasia and superior orbital fissure

asymmetry. Laryngoscope, 92 : 441-448.

15. Elwany S., Abdel-Krelim A., and Tallat M. (1985) : Relevance
of the conventional Water's view in evaluation chronic bacterial
maxillay sinusitis. The Journal of Laryngology and Otology
99: 1233-1244.
16. Hava T. E., Motbey J. E., and Gullane P. J. (1988) : Prevalence
of incidental abnormalities on computed tomographic scans of
the paranasal sinuses. Archives of Otolaryngology and Head
Neck Surgery 114 : 856-859