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CMR Short Reviews The Concept of CMR Historical background on global cardiometabolic risk, epidemiological aspects of obesity and type 2 diabetes, ABCs of cardiovascular disease risk factors, intra-abdominal adiposity, metabolic syndrome and contribution to cardiometabolic risk. The exact pathophysiology that leads to non-alcoholic fatty liver disease and its metabolic consequences has yet to be defined, although a number of plausible explanations have been proposed. What is the prevalence of CVD risk factors among patients with type 2 diabetes, and how do these factors impact clinical management? Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. The content of this website is provided for educational and informational purposes only and is not to be used for medical advice, diagnosis or treatment. Increased fat intake, impaired fat oxidation, and failure of fat cell proliferation result in ectopic fat storage, insulin resistance, and type 2 diabetes mellitus.
Women and men have similar amounts of liver and intra-abdominal fat, despite more subcutaneous fat in women: implications for sex differences in markers of cardiovascular risk. Disordered fat storage and mobilization in the pathogenesis of insulin resistance and type 2 diabetes.
Beta-cell lipotoxicity in the pathogenesis of non-insulin-dependent diabetes mellitus of obese rats: impairment in adipocyte-beta-cell relationships. Molecular evidence supporting the portal theory: a causative link between visceral adiposity and hepatic insulin resistance.
Interaction between free fatty acids and insulin in the acute control of very low density lipoprotein production in humans. Activators of peroxisome proliferator-activated receptor gamma have depot-specific effects on human preadipocyte differentiation. Troglitazone prevents the rise in visceral adiposity and improves fatty liver associated with sulfonylurea therapy--a randomized controlled trial. Improved glycemic control and enhanced insulin sensitivity in type 2 diabetic subjects treated with pioglitazone. This ?spillover? of lipids from adipose tissue to the non-adipose tissues of the liver eventually exceeds the liver?s ability to secrete fatty acids in the form of VLDL (32), causing liver fat. Excess lipid storage in lean tissues such as the liver can then lead to lipid-induced dysfunction (lipotoxicity) (33) and lipid-induced programmed cell death (lipoapoptosis) (34) (Figure 1). Increased delivery of FFA to the liver, particularly from the intra-abdominal (visceral) depot, may be responsible for hepatic insulin resistance (35), triglyceride accumulation in the hepatocytes (15, 36), and increased synthesis and secretion of atherogenic lipoproteins (37). This condition severely limits the ability of adipose tissue to store excess energy, which means excess fat is stored in the liver and muscle, leading to insulin resistance and diabetes (39). To combat this, pharmacological interventions have used thiazolidinediones (TZD), a family of drugs that promote the development of new subcutaneous adipocytes (40) and the expansion of the subcutaneous adipose depot, to decrease liver fat storage (41) and improve insulin sensitivity (42). Introduction Orthodontic treatment should be in harmony with modern medical thought: “It is better to prevent than to cure”. The therapeutic choice is nothing more than the last act in a complete diagnostic process. To be capable of determining the optimum moment to begin treatment, orthodontists must possess a profound comprehension of fundamental information that forms the basis of understanding the pathogenesis of different malocclusions: Normal and pathologic craniofacial growth, orofacial functional behavior, morphogenesis of the dental arches, and child psychology.
Armed with this knowledge, orthodontists can accurately discern which discrepancies would benefit from early treatment and not fall into the trap of indiscriminately treating every patient they examine during the mixed dentition stage [1] . From the eruption of the first primary tooth until the development and eruption of the wisdom teeth, the developing dentition should be monitored and interceptive treatment prescribed as necessary. There is a difference, however, between treatment decisions that are thrust upon us due to aberrations of dental development and types of malocclusion that we may choose to treat early by use of appliance therapy or elective extraction of teeth. The management of certain problems such as skeletal discrepancies or crowding can be undertaken at differing times during the dental development [2] . Although surgery may allow greater changes, there are still limitations to the surgical options, depending on the type of problem and direction of desired jaw movement, and certain problems are more receptive to surgical correction than others.
When dental compensation is present, either naturally or previously produced by orthodontic treatment, these dental positions must be reversed before surgical repositioning of the jaws. The greater the dental compensation is, the smaller the magnitude of jaw movement the surgeon has to correct the skeletal discrepancy.
The term reverse orthodontics is often used in reference to the deliberate movement of teeth in a direction that appears to make the occlusion worse initially when preparing the dentition for orthognathic surgery. When dental compensations exist, they limit the distance and the jaws that can be repositioned to achieve a desirable esthetic result. Greater change can be expected when treating a child (who most likely has some remaining potential for growth) with orthodontic tooth movement plus growth modification than for an adult with camouflage orthodontics alone.
Consequently, given the same severity of skeletal deformities in both a child and an adult, orthodontics alone in the child may produce a desirable result, whereas the adult would not be manageable without a surgical option.
One answer to the question of “When is a problem too severe for orthodontic treatment only?” is “When the combination of tooth movement and growth modification does not have the potential to bring the patient to normal occlusion.” In a growing child, a malocclusion that cannot be corrected by orthodontics in addition to growth modification is severe enough that it merits consideration of a surgical plan. In the non-growing patient, if the malocclusion is too severe to be treated with camouflage orthodontic tooth movement, then a surgical treatment plan should be implemented to obtain a reasonable result. The envelope of discrepancy is based on occlusal considerations, and esthetic limits apply.
Merely obtaining an ideal occlusion at the expense of compromised facial esthetics does not constitute a successful treatment outcome [4] . Defining the Stability of Orthodontic Discrepancy The stability of orthodontic discrepancy as a term describes the type of orthodontic discrepancy deviation by Figure 1.


With the ideal position of the upper incisors shown by the origin of the x and y axes, the envelope of discrepancy shows the amount of change that could be produced by orthodontic tooth movement alone (the inner envelope of each diagram); orthodontic tooth movement combined with growth modification (the middle envelope) and orthognathic surgery (the outer envelope).
Note that the possibilities for each treatment are not symmetric with regard to the planes of space vertical and anteroposterior.
With the ideal position of the lower incisors shown by the origin of the x and y axes, the envelope of discrepancy shows the amount of change that could be produced by orthodontic tooth movement alone (the inner envelope of each diagram); orthodontic tooth movement combined with growth modification (the middle envelope) and orthognathic surgery (the outer envelope). There is more potential to retract than procline teeth and more potential for extrusion than intrusion. Since growth of the maxilla cannot be modified independently of the mandible, the growth modification envelope for the two jaws is the same. Actually there are two main classes of orthodontic discrepancy depending on its stability, Class I which is stable orthodontic discrepancy while Class II is unstable orthodontic discrepancy, additionally Class II unstable orthodontic discrepancy could be divided into two divisions: Regressive orthodontic discrepancy and Progressive orthodontic discrepancy (Figures 3-5). In case of regressive orthodontic discrepancy class, there will be improving in the clinical situation in contrast to the progressive class in which worsening in the clinical situation will be. As the diagrams of the “envelope of discrepancy” (Figure 1, Figure 2, Figure 6 and Figure 7) indicate, the limits vary both by the tooth movement that would be needed (teeth can be moved further in some directions than others) and by the patient’s age (the limits for tooth movement change little if any with age, but growth modification is possible only while active growth is occurring) [5] [6] . One indication for surgery obviously is a malocclusion too severe for orthodontics alone [7] .
Note that the possibilities for each treatment are not symmetric with regard to the planes of space.
There is more potential to retract than procline teeth and more potential for extrusion than intrusion. Since growth of the maxilla cannot be modified independently of the mandible, the growth modification envelope for the two jaws is the same. Surgery to move the lower jaw back has more potential than surgery to advance it [5] [6] . Clinical Applications of Stability of Orthodontic Discrepancy 1) Stable Orthodontic Discrepancy: Spacing between teeth is one of the examples that demonstrates a type of orthodontic discrepancy which is considered stable as it doesn’t worsen by time especially if there is good interdigitation with horizontal growth pattern, the similar situation is in the mild displacement of contact points between teeth which is another type of orthodontic discrepancy as it is the least demanded for orthodontic treatment as shown in (Figure 3, Figure 8 and Figure 9).
The same matter with the diastema between central incisors in early mixed dentition is self limiting as this space tends to close spontaneously when the canines erupt and the incisor root and crown positions change [5] (Figure 4, Figure 5, Figures 10-13). Discussion The stability of orthodontic discrepancy in its broader term is relatively a theoretical concept in spite that it is practical matter as it is simplified the description of orthodontic discrepancy depending on its stability nature as well as facilitate the communication and illustration for orthodontic patients to decide to start treatment early or later as the trend nowadays regarding the decision is a sharing between the orthodontist and patient. Frontal-intraoral view of lower teeth showing ectopic eruption of lower permanent incisors while primary incisors are retained. Primary dentition treatment could begin at age of 4 to 5 [11] . This may be followed up with additional care in the early mixed dentition and more orthodontic treatment in the permanent dentition. The first phase begins in the early mixed dentition at approximately age of 8, and the second phase starts in the permanent dentition at approximately age of 12. Some Orthodontists maintain that early mixed Figure 11. Frontal-intraoral view of lower teeth showing ectopic eruption of  lower permanent incisors while one of primary incisors is exfoliated the other is still retained.
Frontal-intraoral view of lower teeth showing correction of ectopic eruption of lower permanent incisors after 3 months in comparison to Figure 10 and Figure 11.
Frontal-intraoral view showing diastema between central Incisors in early ugly duckling stage. Some authors state that cooperation is better in the mixed dentition with younger patients than the older adolescent patients [10] . Others argue that early orthodontic treatment prolongs orthodontic care and the patient Figure 14. Lateral oblique-intraoral view showing ectopic eruption of maxillary first permanent molar. Orthopantogram showing Ectopic eruption of maxillary right first permanent molar. Frontal-intraoral view showing Ectopic eruption of maxillary right canine and the primary canine is still present. Orthodontic treatment could begin in the late mixed dentition, at approximately age of 11, and treatment would then be limited to one phase of orthodontic care. This approach can be effective in correcting many malocclusions; however, occasionally initiating orthodontic treatment in the late mixed dentition phase can extend treatment time as much as four years while waiting for eruption of all permanent teeth. Patients can experience “burn out” with this potential prolonged treatment time.
Lastly, treatment could begin in the permanent dentition, which could shorten the treatment time and lessen the costs to the patient. The permanent dentition treatment would start upon eruption of the second molars, which may occur from the ages of 10 to 14. Initiating treatment at this stage could present a problem with the physi- Figure 17.
Orthopantogram showing ectopic eruption of maxillary right canine.
Frontal-intraoral view showing anterior cossbite as in pseudo Class III malocclusion. If full-banded orthodontic care is initiated with little or no growth remaining, correcting the Class II malocclusion could become very difficult.


There may be more needed for extractions, surgical orthodontics, or compromised orthodontic treatment when the patient has finished his or her facial growth. One reason for the controversy is that the accepted “cost” of an early treatment time is a two-phase protocol. Phase 1 generally involves 6 to 12 months of active treatment with the intent to change skeletodental relationships. Phase 2 is the “finishing” process after the eruption of appropriate permanent teeth.
Do the benefits of early intervention justify the cost of two-phase treatment?
The Journal of Clinical Orthodontics survey of diagnosis and therapeutics [13] noted that approximately 25% of all patients were treated in a two-phase manner.
The AAO May Bulletin indicated that approximately 1.3 million persons in 1992 elected orthodontic treatment. At 25% of penetration, at least 300,000+ of patients are in a two-phase treatment program. Essentially, a third of all children are treated in two phases. Dugoni School of Dentistry [14] , a comprehensive mixed dentition treatment approach is taught to the orthodontic graduate students. This approach teaches the students to closely evaluate the entire malocclusion of patients who are approximately 7 to 8 years old.
After thorough review of diagnostic records, a treatment plan is established to address the most or all of the problems present in the early mixed dentition. The goal is to eliminate or significantly reduce the need for Phase II orthodontic care. Headgear would be used for correction of most Class II malocclusions. A facemask would be used to protract the maxilla forward in a Class III skeletal pattern. The mandibular arch is usually treated with a lingual arch that is removable and adjustable. The mandibular lingual arch is adjusted at each visit until alignment of the incisors is obtained [14] .
During this supervision stage, the patient wears a removable retainer and continues lingual arch to maintain the alignment of the lower incisors.
Occasionally, headgear is worn during the supervision stage to continue correction of Class II molar position or to prevent rebound toward a Class II problem. The best timing of orthodontic treatment is a decision made by the Orthodontist, the parent, and the patient based on all the factors that impact success. All options should be reviewed with the parent in order that he or she may make an informed decision.
Ferguson [17] wrote that 2-phase treatment was merely a means to capture patients for orthodontic treatment and prevented them from going elsewhere.
Bowman [18] believed that today’s trends are to treat earlier and often. He ridicules braces for baby teeth and asks, “Can in utero treatment be far off?” Turpin [19] summarized the results of the 2002 International Symposium on Early Orthodontic Treatment: Class II correction—A delay in treating Class II problems—Might not compromise treatment results, and it can increase efficiency. All options should be reviewed with the parent in order that he or she may make an informed decision. An early exam allows the orthodontist to offer advice and guidance as to when the optimal time to start treatment would be for that specific patient [20] . Conclusions 1) The cornerstone of best management of orthodontic discrepancy is to identify its stability nature. National Journal of Maxillofacial Surgery, 1, 143-149.
American Journal of Orthodontics & Dentofacial Orthopedics, 113, 75-84. American Journal of Orthodontics & Dentofacial Orthopedics, 108, 556-559.
Journal of the California Dental Association, 10, 807-812. American Journal of Orthodontics & Dentofacial Orthopedics, 130, 799-804. American Journal of Orthodontics & Dentofacial Orthopedics, 113, 62-72. American Journal of Orthodontics & Dentofacial Orthopedics, 110, 14A-15A.
American Journal of Orthodontics & Dentofacial Orthopedics, 121, 335-336.



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