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Levring Jäghagen, Eva, DDS, PhDORCID iD iconorcid.org/0000-0001-8807-3500
Alternative names
Publications (10 of 60) Show all publications
Garoff, M., Ahlqvist, J., Levring Jäghagen, E., Wester, P. & Johansson, E. (2025). Carotid calcifications in panoramic radiographs can predict vascular risk. Dento-Maxillo-Facial Radiology, 54(1), 28-34
Open this publication in new window or tab >>Carotid calcifications in panoramic radiographs can predict vascular risk
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2025 (English)In: Dento-Maxillo-Facial Radiology, ISSN 0250-832X, E-ISSN 1476-542X, Vol. 54, no 1, p. 28-34Article in journal (Refereed) Published
Abstract [en]

Objectives: Carotid artery calcification (CAC) is occasionally detected in panoramic radiographs (PRs). Bilateral vessel-outlining (BVO) CACs are independent risk markers for future vascular events and have been associated with large plaque area. If accounting for plaque area, BVO CACs may no longer be an independent risk marker for vascular events. The aim of this study was to explore the association between BVO CACs and vascular events and its relationship with carotid ultrasound plaque area.

Methods: In this cohort study we prospectively included 212 consecutive participants with CACs detected in PR that were performed to plan and evaluate odontologic treatment. Of these 212, 43 (20%) had BVO CACs. Plaque area was assessed with ultrasound at baseline. Primary outcome was major adverse cardiovascular events (MACEs) during follow-up.

Results: Vessel-outlining CAC was associated with larger plaque area on the same side (P = .03) and BVO CACs were associated with larger total plaque area (both sides summed) than other CAC features (P = .004). Mean follow-up was 7.0 years and 72 (34%) participants had more than 1 MACE. In bivariable analyses, both BVO CACs (HR 2.5, P < .001) and total plaque area (HR 1.8 per cm2, P = .008) were associated with MACE. When entering BVO CACs, plaque area and other relevant co-variates in a multivariable model, BVO CACs were virtually unchanged (HR 2.4, P = .001), but total plaque area was no longer significant (HR 1.0, P = .92).

Conclusion: Present results support the contention that BVO CACs are a stronger predictor for future vascular events than carotid ultrasound plaque area.

Place, publisher, year, edition, pages
Oxford University Press, 2025
Keywords
atherosclerosis, cardiovascular disease, carotid arteries, radiography panoramic, ultrasonography carotid arteries
National Category
Radiology, Nuclear Medicine and Medical Imaging Cardiology and Cardiovascular Disease
Identifiers
urn:nbn:se:umu:diva-233983 (URN)10.1093/dmfr/twae057 (DOI)001378133900001 ()39565902 (PubMedID)2-s2.0-85214318635 (Scopus ID)
Funder
Swedish Heart Lung FoundationThe Swedish Stroke AssociationRegion VästerbottenKnut and Alice Wallenberg Foundation
Available from: 2025-01-13 Created: 2025-01-13 Last updated: 2025-02-10Bibliographically approved
Schulze, R., Klingler, S., Biel, P., Spin-Neto, R., Berkhout, E., Drage, N., . . . Arvidsson, L. (2025). Cone beam computed tomography: Frequency and exposure settings at University (Dental) hospitals in Central and Northern Europe. European Journal of Radiology, 183, Article ID 111886.
Open this publication in new window or tab >>Cone beam computed tomography: Frequency and exposure settings at University (Dental) hospitals in Central and Northern Europe
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2025 (English)In: European Journal of Radiology, ISSN 0720-048X, E-ISSN 1872-7727, Vol. 183, article id 111886Article in journal (Refereed) Published
Abstract [en]

Purpose: To investigate the frequency of CBCT scans, the exposure settings, volume sizes and the patient demographics (age and sex) of patients undergoing CBCT scans in university-based dental hospitals in different European countries over a one-year period.

Method: Eight University Dental Hospitals from eight countries in central and northern Europe agreed to collect data from their CBCT-databases. Exposure data including field of view (FOV), dose area product (DAP) and optimization settings plus (anonymous) age and sex of the patients were collected for the entire year 2023. In addition, centre- and healthcare-system- related characteristics were assembled. Data were statistically evaluated using R Statistical Software.

Results: A total of 7320 CBCT-scans from eight centres and eight different CBCT-machines were evaluated. DAPs ranged between 34 and 4390 mGycm2 (mean: 700.8 mGycm2), kV between 60 kV and 120 kV. Patient age (range 4 yrs to 97 yrs) differed significantly between the centres, yet with a cumulative peak between 10 and 20 yrs. Optimization protocols were observed for all centres, depending on their centre- and also healthcare-characteristics. 21 % of the scans applied some sort of special dose reduction means.

Conclusions: The overall age-peak between 10 and 20 yrs highlights the need to optimized maxillofacial CBCT-protocols. The differences between the centres seem to be mainly related to healthcare-system and centre-related characteristics, which differ largely between the eight centres.

Place, publisher, year, edition, pages
Elsevier, 2025
National Category
Dentistry Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:umu:diva-233378 (URN)10.1016/j.ejrad.2024.111886 (DOI)001391906300001 ()2-s2.0-85212570430 (Scopus ID)
Available from: 2025-01-09 Created: 2025-01-09 Last updated: 2025-04-24Bibliographically approved
Norhammar, A., Näsman, P., Buhlin, K., de Faire, U., Ferrannini, G., Gustafsson, A., . . . Rydén, L. (2025). Does periodontitis increase the risk for future cardiovascular events?: Long-term follow-up of the PAROKRANK study. Journal of Clinical Periodontology, 52(1), 16-23
Open this publication in new window or tab >>Does periodontitis increase the risk for future cardiovascular events?: Long-term follow-up of the PAROKRANK study
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2025 (English)In: Journal of Clinical Periodontology, ISSN 0303-6979, E-ISSN 1600-051X, Vol. 52, no 1, p. 16-23Article in journal (Refereed) Published
Abstract [en]

Background and Aim: The study ‘Periodontitis and Its Relation to Coronary Artery Disease’ (PAROKRANK) reported an association between periodontitis (PD) and the first myocardial infarction (MI). This follow-up study aims to test the hypothesis that those with PD—compared to periodontally healthy individuals—are at increased risk for cardiovascular (CV) events and death.

Methods: A total of 1587 participants (age <75 years; females 19%) had a dental examination including panoramic radiographs between 2010 and 2014. PD was categorized as healthy (≥80% alveolar bone height), mild/moderate (79%–66%) or severe (<66%). A composite CV event (first of all-cause death, non-fatal MI or stroke and hospitalization following to heart failure) was investigated during a mean follow-up period of 9.9 years (range 0.2–12.5 years). Participants were divided into two groups: those with and without PD. The primary event rate, stratified by periodontal status at baseline, was calculated using the Kaplan–Meier method and Cox regression.

Results: The number of events was 187 in the 985 periodontally healthy participants (19%) and 174 in the 602 participants with PD (29%; p < 0.0001). Those with PD had a higher likelihood for a future event (hazard ratio [HR] = 1.26; 95% CI: 1.01–1.57; p = 0.038), following adjustment for age, smoking and diabetes.

Conclusion: The PAROKRANK follow-up revealed that CV events were more common among participants with PD, which supports the assumption that there might be a direct relation between PD and CV disease.

Place, publisher, year, edition, pages
John Wiley & Sons, 2025
Keywords
cardiovascular disease, long-term follow-up, myocardial infarction, periodontitis, prognosis
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-229918 (URN)10.1111/jcpe.14064 (DOI)001310322600001 ()39261983 (PubMedID)2-s2.0-85203707888 (Scopus ID)
Funder
AFA InsuranceSwedish Heart Lung FoundationSwedish Research CouncilSwedish Society of MedicineRegion Stockholm
Available from: 2024-09-25 Created: 2024-09-25 Last updated: 2025-01-10Bibliographically approved
Ahlqvist, J., Levring Jäghagen, E., Friedlander-Barenboim, S., Clarkson, R., Ferreira Da Costa, J., Fisekcioglu, E., . . . Lindh, C. (2025). Resources allocated for undergraduate education in oral radiology in European dentistry programmes: a survey study. European journal of dental education, 29(2), 384-391
Open this publication in new window or tab >>Resources allocated for undergraduate education in oral radiology in European dentistry programmes: a survey study
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2025 (English)In: European journal of dental education, ISSN 1396-5883, E-ISSN 1600-0579, Vol. 29, no 2, p. 384-391Article in journal (Refereed) Published
Abstract [en]

Aims: The Education Committee of the European Academy of DentoMaxilloFacial Radiology should ‘encourage and support high levels of graduate and postgraduate education in dentomaxillofacial radiology (DMFR) all over Europe’. For this reason, the committee aimed to formulate a document describing resources allocated for undergraduate education within oral radiology in Europe today that can serve as a benchmark against which dental schools and/or countries with dentistry programmes can relate their undergraduate education.

Materials and Methods: A questionnaire addressing resources allocated for learning oral radiology was distributed to colleagues involved in oral radiology education in 117 dental schools in 29 countries in Europe.

Results: The answers represent approximately 13% of the dental schools in 40% of the countries providing dental education in Europe. There was a large variation regarding qualifications among teachers. There were also large differences in reported time dedicated to oral radiology courses, within some parts the allocated time differed by a factor 16.

Discussion: An ambition to achieve high standards in oral radiology all over Europe should, based on the results of this survey, start with an effort to attain consensus regarding the role of oral radiology in dental education. The involvement of dentists with DMFR specialist training, would support high levels of undergraduate education.

Conclusion: The results of this survey include information that educators and authorities can relate to in planning and implementation of new or revised curriculum. The ambition should be to increase teachers' competence and to work towards more harmonised and extensive courses in oral radiology.

Place, publisher, year, edition, pages
John Wiley & Sons, 2025
Keywords
curriculum, dental, education, radiology, undergraduate
National Category
Odontology
Identifiers
urn:nbn:se:umu:diva-236488 (URN)10.1111/eje.13078 (DOI)001468028100001 ()39973014 (PubMedID)2-s2.0-105003006673 (Scopus ID)
Available from: 2025-03-18 Created: 2025-03-18 Last updated: 2025-04-29Bibliographically approved
Selg, J., Holmlund, T., Levring Jäghagen, E., McGreevy, J., Svanberg, S., Wester, P. & Hägglund, P. (2025). Validity and reliability of the Swedish version of the gugging swallowing screen for use in acute stroke care. Dysphagia (New York. Print), 40, 176-186
Open this publication in new window or tab >>Validity and reliability of the Swedish version of the gugging swallowing screen for use in acute stroke care
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2025 (English)In: Dysphagia (New York. Print), ISSN 0179-051X, E-ISSN 1432-0460, Vol. 40, p. 176-186Article in journal (Refereed) Published
Abstract [en]

The purpose of this study was to cross-culturally validate the Swedish version of the Gugging Swallowing Screen (GUSS-S) for use in the acute phase of stroke. Further, to evaluate the inter-rater reliability between different healthcare professionals. GUSS was translated into Swedish using a forward-backward method followed by expert rating to obtain content validity. For criterion validity, the GUSS-S score was compared with Flexible Endoscopic Evaluation of Swallowing (FEES) assessed with the Penetration-Aspiration Scale (PAS) in acute stroke patients (≤ 96 h after stroke onset). Convergent validity was calculated by comparison with the Functional Oral Intake Scale (FOIS) as per the comprehensive FEES assessment, the Standardized Swallowing Assessment (SSA), and the National Institutes of Health Stroke Scale (NIHSS). To evaluate inter-rater reliability, a nurse and a speech-language pathologist (SLP) independently assessed 30 patients. In total, 80 patients (32 women, median age 77 years (range 29–93) were included, mean 1.7 ± 0.9 days after admission. With a cut-off value of 14 points, the GUSS-S identified aspiration with a sensitivity of 100% and a specificity of 73% (area under the curve: 0.87, 95% CI 0.78–0.95). Spearman rank correlation showed very strong correlation between the GUSS-S and PAS (rs=-0.718, P = < 0.001) and FOIS (rs=0.720, P = 0.001) and strong correlation between the GUSS-S and SSA (rs=0.545, P = < 0.001) and NIHSS (rs=-0.447, P = 0.001). The inter-rater agreement for GUSS-S was substantial (Kw=0.67, P = < 0.001). The results indicate that the GUSS-S is a valid and reliable tool for the assessment of dysphagia in acute stroke patients by different healthcare professionals.

Place, publisher, year, edition, pages
Springer, 2025
Keywords
Stroke, Dysphagia screening, Validation, Sensitivity, Specificity, The Gugging swallowing screen
National Category
Otorhinolaryngology Neurology
Identifiers
urn:nbn:se:umu:diva-225527 (URN)10.1007/s00455-024-10717-y (DOI)001226594800001 ()38753206 (PubMedID)2-s2.0-85193223225 (Scopus ID)
Available from: 2024-06-03 Created: 2024-06-03 Last updated: 2025-05-28Bibliographically approved
Bladh, M., Gustafsson, N., Engström, G., Kennbäck, C., Klinge, B., Nilsson, P. M., . . . Levring Jäghagen, E. (2024). Defined shapes of carotid artery calcifications on panoramic radiographs correlate with specific signs of cardiovascular disease on ultrasound examination. Oral surgery, oral medicine, oral pathology and oral radiology, 137(4), 408-420
Open this publication in new window or tab >>Defined shapes of carotid artery calcifications on panoramic radiographs correlate with specific signs of cardiovascular disease on ultrasound examination
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2024 (English)In: Oral surgery, oral medicine, oral pathology and oral radiology, ISSN 2212-4403, E-ISSN 2212-4411, Vol. 137, no 4, p. 408-420Article in journal (Refereed) Published
Abstract [en]

Objective: The aim was to optimize diagnostics for carotid artery calcifications (CACs) on panoramic radiographs (PRs) to identify cardiovascular disease (CVD) by investigating how 4 defined CAC shapes are associated with ultrasound (US) findings indicating CVD.

Study Design: The study included 414 participants (802 neck sides) from the Malmö Offspring Dental Study, examined with PRs. The PRs were assessed for CAC shapes stratified into 4 categories: single, scattered, vessel-width defining, and vessel-outlining. The carotid arteries were examined with US for signs of CVD: the presence of plaques, largest individual area of a plaque, number of plaques, and percentage reduction of the lumen. Associations between the different CAC categories and US characteristics were analyzed.

Results: All categories of CAC were significantly associated with a higher degree of US findings indicating CVD compared with no CAC (P < .001). The most significant differences were found for vessel-outlining CAC, with the mean of the largest individual plaque area of 17.9 vs 2.3 mm2, mean number of plaques 1.6 vs 0.2, and mean percentage reduction of the lumen 24.1% vs 3.5% (all P < .001).

Conclusions: Independent of shape, CACs detected on PRs were associated with a higher degree of US findings of CVD. This was most pronounced for vessel-outlining CAC. With refined differential diagnostics of CACs in PRs, dentists may contribute to improved identification of patients in need of cardiovascular prevention.

Place, publisher, year, edition, pages
Elsevier, 2024
National Category
Dentistry Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:umu:diva-220848 (URN)10.1016/j.oooo.2023.12.783 (DOI)001223183900001 ()38320892 (PubMedID)2-s2.0-85183975366 (Scopus ID)
Funder
Region Västerbotten, 7003195Region Västerbotten, 7004491Umeå UniversitySwedish Dental AssociationThe Kempe Foundations
Available from: 2024-02-20 Created: 2024-02-20 Last updated: 2025-04-24Bibliographically approved
Lundberg, J., Al-Taai, N., Levring Jäghagen, E., Ransjö, M. & Sjöström, M. (2024). Skeletal stability after maxillary distraction osteogenesis or conventional Le Fort i osteotomy in patients with cleft lip and palate: a superimposition-based cephalometric analysis. Oral and Maxillofacial Surgery, 28(2), 925-934
Open this publication in new window or tab >>Skeletal stability after maxillary distraction osteogenesis or conventional Le Fort i osteotomy in patients with cleft lip and palate: a superimposition-based cephalometric analysis
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2024 (English)In: Oral and Maxillofacial Surgery, ISSN 1865-1550, E-ISSN 1865-1569, Vol. 28, no 2, p. 925-934Article in journal (Refereed) Published
Abstract [en]

Purpose: The aim was to assess skeletal stability after maxillary advancement using either distraction osteogenesis (DO) or conventional Le Fort I osteotomy (CO) in patients with cleft lip and palate (CLP) or cleft palate (CP) utilising a new superimposition-based cephalometric method.

Method: This retrospective study included patients who were treated with DO (N = 12) or CO (N = 9). Sagittal and vertical changes after surgery, and skeletal stability at 18 months post-operatively were assessed with superimposition-based cephalometry, comparing lateral cephalograms performed pre-operatively (T0), post-operatively after CO or immediately after completed distraction in DO (T1), and at 18 months of follow-up (T2).

Results: The mean sagittal movements from T0 to T2 in the DO and CO groups were 5.9 mm and 2.2 mm, respectively, with a skeletal relapse rate of 16% in the DO group and 15% in the CO group between T1 and T2. The vertical mean movement from T0 to T2 in the DO and CO groups was 2.8 mm and 2.0 mm, respectively, and the skeletal relapse rate between T1 and T2 was 36% in the DO group and 32% in the CO group.

Conclusion: Sagittal advancement of the maxilla was stable, in contrast to the vertical downward movement, which showed more-extensive relapse in both groups. Despite more-extensive maxillary advancement in the DO group, the rates of skeletal relapse were similar.

Place, publisher, year, edition, pages
Springer Nature, 2024
Keywords
Distraction osteogenesis, Maxillary repositioning, Orthognathic surgery, Skeletal relapse, Cleft lip and palate
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-221090 (URN)10.1007/s10006-024-01227-0 (DOI)001163526500001 ()38363518 (PubMedID)2-s2.0-85185143089 (Scopus ID)
Funder
Umeå University, 396178205
Available from: 2024-02-19 Created: 2024-02-19 Last updated: 2024-06-18Bibliographically approved
de Lange, T., Møystad, A., Torgersen, G., Ahlqvist, J. & Levring Jäghagen, E. (2024). Students' perceptions of post-exam feedback in oral radiology: a comparative study from two dental hygienist educational settings. European journal of dental education, 28(2), 377-387
Open this publication in new window or tab >>Students' perceptions of post-exam feedback in oral radiology: a comparative study from two dental hygienist educational settings
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2024 (English)In: European journal of dental education, ISSN 1396-5883, E-ISSN 1600-0579, Vol. 28, no 2, p. 377-387Article in journal (Refereed) Published
Abstract [en]

Introduction: The aim of this study was to investigate how students perceive the benefit of participating in a teacher-organised session providing feedback on exams, termed post-exam feedback, in two dental hygienist programmes.

Methods: The study was based on interviews with 22 participants, including 18 students and 4 faculty teachers. The data were approached on the basis of thematic analysis, allowing us to generate insights on how the participants reflected on their participation in the post-exam feedback sessions and how they perceived this arrangement as learners.

Results: The findings from the study suggest that motivated students consider post-exam feedback to be beneficial in clearing up uncertainties and deepening their understanding of issues not fully understood during the exam, as well as supporting their further learning. Less motivated students mainly consider post-exam feedback to be relevant for students who do not pass the exams.

Conclusions: Organised in a student-centred way and with attentiveness to student learning preferences, the results suggest that post-exam feedback can be valuable for enhancing assessment and supporting student learning related to exams.

Place, publisher, year, edition, pages
John Wiley & Sons, 2024
Keywords
Assessment, oral radiology, post-exam feedback, student learning
National Category
Dentistry
Identifiers
urn:nbn:se:umu:diva-216218 (URN)10.1111/eje.12959 (DOI)001089702100001 ()37885281 (PubMedID)2-s2.0-85175033873 (Scopus ID)
Funder
Umeå University
Available from: 2023-11-06 Created: 2023-11-06 Last updated: 2024-07-03Bibliographically approved
Jonsson, A., Holmer, J., Kullman, L., Eriksdotter, M., Ahlqvist, J., Levring Jäghagen, E. & Buhlin, K. (2023). Calcified carotid artery atheromas in individuals with cognitive dysfunction. Acta Odontologica Scandinavica, 81(4), 325-331
Open this publication in new window or tab >>Calcified carotid artery atheromas in individuals with cognitive dysfunction
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2023 (English)In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 81, no 4, p. 325-331Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this case-control study was to investigate whether cognitively impaired individuals have a higher burden of calcified carotid artery atheroma (CCAA) than controls without cognitive impairment.

Material and methods: The study included 154 cases with Alzheimer’s disease (n = 52), mild cognitive impairment (n = 51), or subjective cognitive decline (n = 51) diagnosed at a university memory clinic. Seventy-six cognitively healthy controls were sampled through the Swedish population register. All participants underwent clinical oral and panoramic radiographic examinations. Two oral and maxillofacial radiologists performed blinded analyses of the panoramic radiographs for signs of CCAA, which was registered as absent or present and, if present, unilateral or bilateral. Consensus assessment was used for all statistical analyses.

Results: CCAA was common (40%) in this middle-aged and older Swedish population. We found no differences in the prevalence of CCAA between cases and controls (40% vs. 42%).

Conclusion: Cognitively impaired patients do not have a higher burden of CCAA than matched controls without cognitive impairment.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2023
Keywords
Alzheimer’s disease, cardiovascular disease, cognitive disorders, dentistry, panoramic radiography
National Category
Dentistry Radiology, Nuclear Medicine and Medical Imaging Geriatrics
Research subject
Odontology
Identifiers
urn:nbn:se:umu:diva-201842 (URN)10.1080/00016357.2022.2152863 (DOI)000900707600001 ()36538364 (PubMedID)2-s2.0-85144537909 (Scopus ID)
Funder
Stockholm County Council
Available from: 2022-12-21 Created: 2022-12-21 Last updated: 2023-06-19Bibliographically approved
Al-Taai, N., Persson, M., Ransjö, M., Levring Jäghagen, E. & Westerlund, A. (2023). Dentoskeletal and soft tissue changes after treatment of crowding with premolar extractions: a 50-year follow-up. European Journal of Orthodontics, 41(1), 79-87
Open this publication in new window or tab >>Dentoskeletal and soft tissue changes after treatment of crowding with premolar extractions: a 50-year follow-up
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2023 (English)In: European Journal of Orthodontics, ISSN 0141-5387, E-ISSN 1460-2210, Vol. 41, no 1, p. 79-87Article in journal (Refereed) Published
Abstract [en]

Background: The long-term effects on dentofacial morphology of interceptive treatment with premolar extractions, in the absence of subsequent orthodontic treatment, have not been fully explored.

Objective: The aim was to investigate the effects of premolar extractions (without subsequent orthodontic treatment) on the dentoskeletal and soft tissue profile of patients aged between 12 and 62 years with Class I malocclusion with severe crowding, as compared to untreated controls.

Materials and methods: The Extraction group (N = 30 with Class I crowding malocclusion) had their first premolars removed in early adolescence without subsequent orthodontic treatment. The Control group included 30 untreated subjects with Class I normal occlusion. Cephalograms were taken at 12 (T1), 15 (T2), 30 (T3), and 62 (T4) years of age. A superimposition-based cephalometric method was used to assess the dentoskeletal and soft tissue changes.

Results: There were no significant differences between the Extraction and Control groups in terms of skeletal sagittal relation, incisor inclination, and protrusion, or most of the soft tissue parameters throughout the observation period. However, significant differences were observed between the groups with respect to the vertical relations in T2-T3, such that the Extraction group showed more-pronounced decreases in the ML/NSL, ML/NL, and Gonial angles and more-pronounced increases in facial heights.

Conclusions and implications: Treatment for subjects with Class I malocclusion with severe crowding by the extraction of four premolars, without subsequent orthodontic treatment, does not affect the long-term dentoskeletal and soft tissue profile, as compared to an untreated Control group. The degree of crowding, rather than changes in dentofacial morphology, is crucial in deciding on extraction therapy.

Place, publisher, year, edition, pages
Oxford University Press, 2023
National Category
Dentistry Surgery
Research subject
Odontology
Identifiers
urn:nbn:se:umu:diva-199060 (URN)10.1093/ejo/cjac035 (DOI)000820957600001 ()35791441 (PubMedID)2-s2.0-85147834504 (Scopus ID)
Funder
Umeå University
Available from: 2022-09-02 Created: 2022-09-02 Last updated: 2023-03-06Bibliographically approved
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