European Journal of Orthodontics, 2020, 643–649

doi:10.1093/ejo/cjz104
Advance Access publication 15 January 2020

Original article

Changes in mandibular shape after early

treatment in subjects with open bite: a
geometric morphometric analysis

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Roberta Lione1,2, Dimitri Fusaroli1, Manuela Mucedero1, Valeria Paoloni1,
Chiara Pavoni1,2 and Paola Cozza1,2
Department of Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome, Italy
1

Department of Orthodontics, University Zoja e Këshillit të Mirë, Tirane, Albania

2

Correspondence to: Dimitri Fusaroli, Department of Clinical Sciences and Translational Medicine, University of Rome “Tor
Vergata”, Viale Oxford, 81, Rome 00133, Italy. E-mail: dimitri.fusaroli@hotmail.com

Summary
Objectives:  To evaluate the mandibular modifications in anterior open bite (OB) growing subjects
treated with Rapid Maxillary Expansion and bite block (RME/BB) or Quad Helix with crib (QH/C)
when compared with a Control Group (CG) by using Geometric Morphometric Method (GMM) and
conventional cephalometric.
Materials:  The OB group comprised 34 subjects (26 girls, 8 boys) with dentoskeletal OB and a mean age
of 8.0 ± 1.0 years. OB group was divided in two subgroups: RME/BB group comprised 17 subjects (13 girls,
4 boys), while QH/C group included 17 subjects (13 girls, 4 boys). The two subgroups were compared
with a CG of 17 subjects (13 girls, 4 boys) matched for sex, age, vertical pattern, and observation periods.
Two consecutives lateral cephalograms were available: the first one was taken before treatment (T1),
and the second one was acquired at a follow-up observation at least 4 years after the completion of
treatment (T2). Landmarks and semilandmarks were digitized on lateral cephalograms and GMM was
applied. Procrustes analysis and principal component analysis were performed. Analysis of variance
(ANOVA) with Tukey post hoc tests was used to compare the T2–T1 cephalometric changes between the
RME/BB, QH/C, and CG.
Results:  In the long term, RME/BB showed a significantly greater decrease of the Condylar axis
to mandibular plane angle when compared to CG and QH/C. GMM showed an increased in height
of the mandibular ramus in RME/BB group with tendency to counterclockwise rotation of the
mandible when compared with QH/C and CG groups.
Conclusions:  RME/BB subjects showed significant changes in the shape of the mandibular ramus
with a counterclockwise rotation tendency when compared with QH/C and CG subjects.

Introduction lymphatic tissue, heredity, oral functional matrices, unfavourable

growth patterns, and constricted maxilla (5–11).
Anterior open bite (OB) is defined by the absence of occlusion be-
A reduced depth of the bite can be associated with skeletal hyper-
tween the incisal margins of the superior and inferior teeth when the
divergence, otherwise referred to as long-face syndrome or high-
remaining teeth are in occlusion (1–3).
angle disharmony (12–14).
OB is a consequence of many aetiologic factors, both hereditary
In the aetiology of skeletal OB, an unfavourable growth pat-
and environmental in nature (4). Many potential aetiological fac-
tern characterized by excessive gonial, small mandibular body and
tors have been considered, including digit sucking habits, enlarged
ramus, increased anterior and decreased posterior facial height,

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Orthodontic Society.
643
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644 European Journal of Orthodontics, 2020, Vol. 42, No. 6

steep anterior cranial base, and a narrow maxillary arch, plays an
important role (11–15). Dental and dentoalveolar OB are the result
of a mechanical blockage of the vertical development of the inci-
sors while skeletal relationships are normal. However, in most cases,
the distinction is not clear since malocclusion presents both dental
and skeletal components. In literature, a broad diversity in terms of
therapeutic approaches has been proposed in the early management
of skeletal OB. Some studies have found a correlation between long-
face and maxillary constriction. The most consistent maxillary char-
acteristic is to be narrowed with an increased incidence of posterior
crossbites (16). For this reason, many investigators (3,17–20) have
stressed that a skeletal OB should be managed early in growing sub-
jects by applying Rapid Maxillary Expansion (RME) in association
with a posterior bite block (BB) to control the vertical dimension
subjects when compared with an untreated CG by using conven-
tional cephalometric and GMM.
Materials and methods
A sample of 34 OB subjects (26 girls, 8 boys) with a mean age of
8.0  ± 1.0  years was collected retrospectively from the archives of
the Department of Orthodontics of the University of Rome “Tor
Vergata”.
The patients included in the study group were selected according
to the following inclusion criteria: European ancestry (white), over-
bite less than 0  mm, increased vertical dimension as assessed on
lateral cephalograms (SN^GoGN >37°) (26), posterior transverse
interarch discrepancy ≥3  mm (27), mixed dentition stage, pre-

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by avoiding the extrusion of both lower and upper molars. Sankey
et al. (21) reported this type of intervention significantly improved
condylar growth to a more anterosuperior direction, and produced
anterior mandibular rotation 2.7 times greater than the controls.
On the contrary, in non-nutritive sucking patients with negative
overbite early treatment has been proposed to eliminate the pro-
longed thumb-sucking habit often associated with reduced maxillary
arch and increased palatal depth (22).
The Quad Helix with crib (QH/C) protocol produces a clin-
ically significant improvement in the vertical skeletal relation-
ships because of a reported downward rotation of the palatal
plane (3).
Previously, one study (23) assessed the morphological shape vari-
ations of the palatal vault in OB growing subjects when compared
with a Control Group (CG) by means of Geometric Morphometric
Method (GMM) that has been used in the literature as method of
visualization of shape changes (24,25).
In 2018, Mucedero et al. (20) evaluated the long-term effects of
only RME/BB treatment using the cephalometric analysis and not
morphometric analysis, focusing mainly on dental and maxillary
changes, but not on mandibular ones.
To our knowledge, no data are available with regard to morpho-
logical variation of the mandible in OB growing subjects, after the
completion of entire treatment.
Therefore, the aim of this study was to analyse the morphological
characteristics of the mandible at the end of growth, in OB treated
pubertal skeletal maturation (CS1–CS2) (28), and good quality of
lateral cephalograms (Table 1).
Exclusion criteria included: previous orthodontic treatment,
appliance breakage, multiple and/or advanced caries, tooth agen-
esis, supernumerary teeth, cleft lip and/or palate, and other genetic
diseases.
The initial OB group was divided in two subgroups according
to the presence or absence of prolonged sucking habits and conse-
quently according to treatment strategy. When the sucking habit was
not recorded the patient was treated by RME/BB, otherwise when
the sucking habit was observed the subject was treated by applying
QH/C. The first subgroup, RME/BB group was composed of 17 sub-
jects (13 girls, 4 boys) with a mean age of 7.9 ± 0.7 years with no
referral of sucking habits. The second subgroup, QH/C group was
composed of 17 (13 girls, 4 boys) with a mean age of 8.1 ± 1.3 years
with referred thumb-sucking habits from a minimum of 6 hours or
more per day, or referred persisting sucking habit at night with the
parents reporting sucking noise (29,30).
Headfilms were collected before treatment (T1) and at a
follow-up observation at least 4 years after the completion of treat-
ment (T2) using a modern cephalostat with 1.5 m of focus/film dis-
tance. This project was approved by the ethical committee at the
University of Rome “Tor Vergata” (protocol number 168/19) to ac-
cess to the archive and to use patient personal information for re-
search purposes. Parents of all subjects included the subjects were
recalled to sign an informed consent.

Table 1.  Demographics and statistical comparison of starting forms between Rapid Maxillary Expansion and bite block (RME/BB) group,
Quad-Helix with Crib (QH/C) group, and control group (CG) by means of analysis of variance (ANOVA) with Tukey post hoc tests (P < 0.05).

RME/BB QH/C CG
(n = 17, 13 f (n = 17, 13 f (n =1 7, 13 f TUKEY post hoc tests
Measurements 4 m) 4 m) 4 m) ANOVA (P value)

QH/C versus RME QH/C versus CG RME versus CG

Mean SD Mean SD Mean SD P value P value P value P value

Age at T1 (years) 7.9 0.7 8.1 1.3 8.0 0.7 NS NS NS NS

0.786 0.672 0.723
Age at T2 (years) 13.3 1.3 13.5 1.8 13.3 1.2 NS NS NS NS
0.933 0.998 0.956
T1–T2 interval (years) 5.4 1.5 5.4 1.5 5.3 1.2 NS NS NS NS
0.475 0.639 0.726
Overbite (mm) −2.6 1.2 −2.7 1.1 −2.9 1.2 NS NS NS NS
0.405 0.553 0.447
SN^GoGN (deg) 42.3 4.1 41.7 3.8 41.2 4.4 NS NS NS NS
0.553 0.644 0.723

SD = standard deviations; NS = not significant; SN^GoGN (deg) = canial base to mandibular plane angle.
R. Lione et al.
Each subject of the RME/BB sample underwent a therapy with
RME soldered to bands on the first permanent molars or on the second
deciduous molars (Figure 1). The expansion screw was turned one time
a day until the palatal cusps of the upper posterior teeth approximated
the buccal cusps of the lower posterior teeth; then the appliance was
left in place for at least 8 months as a passive retainer to make stable
the expansion reached during screw activation. After RME removal, no
other device was prescribed to the patient. The BB appliance was pro-
jected in the form of a Schwartz device for the mandibular arch with
resin splints of 5-mm thickness in the posterior occlusal region. The
BB was applied for 12 months to control the vertical dimension. The
patients wear the BB 24 hours a day. Compliance differed among pa-
tients, as in researches requiring any removable appliance. Therefore, a
single investigator conducted a face-to-face interview with each patient
to establish the cooperation. Compliance was assessed with a 3-point
Likert-type scale (poor, moderate, and good) (31): poor compliance
was declared when the patient wore the BB at night only, moderate
compliance happened when the patient wore the BB at night and dur-
ing the day at home, and good compliance was established when the
patient wore the BB full time as suggested by the clinician (20).
Each subject of the QH/C sample underwent a treatment therapy
with a QH/C device made of 0.036-in stainless steel wire soldered
to bands on the first permanent molars or on the second deciduous
molars. The lingual arms of the device developed mesially to the de-
ciduous canines or to the permanent incisors. The anterior helices
were placed as far forward on the palate as possible. To prevent
thumb sucking, spurs were added. They were formed from three seg-
ments of 0.036-in stainless steel wire soldered to the anterior bridge
of the QH/C. The three segments were inclined lingually to prevent
impingement on the sublingual mucosa (3,32).
QH/C activation was correspondent to the buccolingual
width of 1 molar. The device was reactivated once or twice during
Figure 1.  (A) Rapid maxillary expander. (B) Posterior bite block appliance.
645
therapy to reach overcorrection of the transverse relationships
(Figure 2).
Seventeen subjects (13 girls, 4 boys) with a mean age of 8.0  ±
0.7 years and untreated anterior OB were chosen from the American
Association of Orthodontists Foundation Craniofacial Growth
Legacy Collection (http://www.aaoflegacycollection.org) to form a
CG. The untreated anterior OB subjects matched the RME/BB and
QH/C groups for negative overbite at T1, chronologic age, skeletal
vertical dysplasia [increased vertical dimension as assessed on lat-
eral cephalograms (SN^GoGN>37°) (26)], and skeletal maturation
at the various time periods and for the duration of intervals. Studied
groups’ demographic data are examined in Table 1.
Cephalometric software (Viewbox, version 4.0, dHAL Software,
Kifissia, Greece) was used for a customized digitization regimen used
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for the conventional cephalometric evaluation.
Headfilms of both treated groups (TGs) and of CG were stand-
ardized with regard to magnification factor by setting this at 0%.
The cephalometric reference points, lines, and angles (four an-
gular measurements) used in the analysis are shown in Figure  3.
Cephalometric analysis was performed according to the method of
Baccetti et  al. (33) to assess ramus inclination to cranial base and
mandibular plane. Specifically, the stable basicranial line, through
the most superior point of the anterior wall of sella turcica at the
junction with the tuberculum sellae (point T) (34), was drawn tan-
gent to the lamina cribrosa of the ethmoid bone.
To study mandibular structures, GMM was applied (24,25,35).
Cephalometric software (Viewbox, version 4.0, dHAL Software,
Kifissia, Greece) was used to digitize the cephalogram of each sub-
ject. For the evaluation of the shape of the mandible 2 continuous
curves (Table 2) with 31 points, 5 of them being fixed cephalometric
landmarks were drawn (Figure  4). The remaining landmarks were
semilandmarks, initially placed at equidistant distances along the
curves. The averages of all the datasets (mandible) were calculated,
and used as a fixed reference (Procrustes average) to allow all sem-
ilandmarks to slide and become more homologous from subject to
subject in order to minimize the thin-plate spline bending energy
(24,36,37). This procedure was redone twice. All digitization of
radiographs and study casts were executed by the same operator
and analysed using the Generalized Procrustes method.
Statistical analysis
Cephalometric measurements
To determine the method error, measurements on the lateral cepha-
lograms of RME/BB, QH/C, and CG groups were performed by one
Figure 2.  Quad Helix with crib.
646
trained examiner (DF) and repeated after an interval of approxi-
mately 2 weeks. A paired t-test was used to compare the two meas-
urements (systematic error).
Statistical between-group comparisons were calculated for the
craniofacial starting forms at T1. The three groups matched in terms
of skeletal relationship and skeletal maturation.
In the presence of normally distributed data, statistical between-
group comparisons for the T2–T1 changes were performed using
ANOVA with Tukey post hoc tests (P < 0.05).
Geometric morphometric analysis
To determine the reliability of the method, 20 lateral cephalograms
were randomly selected and redigitized by the same trained oper-
ator (DF) almost 2 weeks after the first digitization. Random error
was expressed as the distance between repeated digitizations in
shape space compared with the total variance of the sample (38).
Procrustes analysis was applied and principal component analysis
was performed to reveal the main patterns of mandibular shape
variation. Procrustes distance between group means was used to
Figure 3.  Cephalometric points, lines, and angles used in analysis: Condylar
axis (CondAx) passing through points Co and Cc (midpoint between the two
Articulare points Ar and Ara); Stable basicranial line (SBL) traced through
the most superior point of the anterior wall of sella turcica at the junction
with tuberculum sellae (point T), drawn tangent to lamina cribrosa of the
ethmoid bone; CondAx to mandibular plane (MP); CondAx to SBL; CondAx
to Frankfort horizontal (Po-Or); CondAx to SN.
Table 2. Description of the curves of the mandible (some points
are common between curves).
Curves Description N° Points
Mandible From infradental, along the external 25
outline of the mandible around the
condyle, to the anterior neck of the condyle
Symphysis The lingual cortical plate of the symphysis 6 Figure 4. Fixed landmarks (green circles) and sliding semilandmarks (red
European Journal of Orthodontics, 2020, Vol. 42, No. 6
evaluate the statistical differences between the groups at T2: RME/
BB versus QH/C; RME/BB versus CG; QH/C versus CG. More than
10 000 permutations have been reported (25).
Results
All subjects were at a prepubertal stage of skeletal maturity ac-
cording to the cervical vertebral maturation method (CS1 or CS2)
at T1 (28). All subjects had reached postpubertal skeletal maturity
at T2 (CS 4–6). The stages of cervical vertebral maturation were de-
termined by a calibrated examiner trained in this method showing
that almost subjects reached at T2 CS5 or CS6 stage. Only the 30%
of the total treated and untreated sample presented a CS4 stage.
The remaining 70% reached CS5–CS6 stages. All patients were in
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the permanent dentition at T2. At T1 RME/BB subjects showed a
posterior transverse interarch discrepancy of 5.2 ± 0.3 mm while
QH/C patients presented a constricted maxillary arch discrepancy
of 4.4 ± 0.2 mm.
In both TGs the protocol treatment lasted almost 1 year, until a
positive overbite was reached.
The analysis of compliance of the RME/BB subjects (use of BB)
showed that none had poor cooperation, 5 had moderate cooper-
ation, and the remaining 12 patients had good compliance. As a re-
sult, cooperation was good in 70.6% of the patients.
In the RME/BB group 12 patients, while in the QH/C 11 sub-
jects performed a second phase with fixed conventional appliance
to finish the occlusion. No active biomechanics or vertical elastics to
extrude the incisors were applied during fixed appliance therapy. No
intraoral Class II elastics or bite ramps on posterior teeth or other
anterior extrusive/posterior intrusive mechanics were used.
No systematic error was found between the repeated cephalo-
metric values; while the mean random error of the 20 repeated digi-
tizations for the geometric morphometric analysis, expressed as a
percentage of total shape variance, was 3.7%.
Cephalometric measurements
The comparisons of long-term changes (T2–T1), shown in (Table 3),
revealed a significantly greater decrease of the Condax^MP angle
in RME/BB group when compared to CG and QH/C (P = 0.0002;
crosses) used to describe the mandible.
R. Lione et al. 647

Table 3.  Statistical comparisons of theT2–T1 cephalometric measurements changes between Rapid Maxillary Expansion and bite block (RME/BB)
group, Quad-Helix with Crib (QH/C) group, and control group (CG) by means of analysis of variance (ANOVA) withTukey post hoc tests (P < 0.05).

Cephalometric RME/BB QH/C CG

measurements (n = 17) (n = 17) (n = 17) ANOVA Tukey post hoc tests (P value)

QH/C versus RME QH/C versus CG RME versus CG

Mean SD Mean SD Mean SD F P value P value P value P value

Condax^MP (deg) −6.0 2.6 −3.5 3.6 −2.0 1.4 9.6 ***
* NS *** 0.0002
0.025 0.244
Condax^SBL (deg) 6.2 3.5 2.9 5.4 2.8 2.2 4.1 * * NS *
0.046 0.998 0.0411
Condax^PF (deg) 3.7 2.3 2.4 4.8 2.9 2.0 0.7 NS NS NS NS
0.475 0.912 0.726
Condax^SN (deg) 3.6 3.1 2.1 4.5 2.6 2.1 0.8 NS NS NS NS
0.405 0.913 0.650

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PF = Frankfort horizontal; SD = standard deviations; NS = not significant.
*P < 0.05.
***P < 0.001.

P = 0.025). A decrease of the angle was also noticed in QH/C group

compared to CG, but the difference between these two groups was
not statistically significant.
Moreover, RME/BB group showed a statistically significant in-
crease in the Condax^BSL angle when compared to the other two
groups (P = 0.046; P = 0.0411).
No statistically significant differences between the three groups
were found in both the Condax^PF and Condax^SN measurements.

Geometric morphometric analysis

For the changes in the mandibular morphology, a statistically sig-

nificant difference between the mandibular shape of RME/BB versus
QH/C groups and RME/BB versus CG groups was found (10 000
permutations; P = 0.046; P = 0.023) (Supplementary Figures 1–3).
The first principal component (PC1) explained the largest variance
and was morphologically considered to be the most meaningful.
By comparing RME/BB and QH/C groups, the variation de-
scribed by PC1 defined the 29% of total shape variance (PC1: 29%, Figure 5. Morphological mandibular comparison between RME/BB (blue)
PC2: 16.6%, PC3: 12.1%, PC4: 8.4%, PC5: 7.1%). PC1 showed and QH/C (yellow).
significant changes within the observed growth period. The man-
dibular ramus increased in height in RME/BB group with tendency
to the counterclockwise rotation of the mandible (Figure  5 and
Supplementary Figure 3a–c). Similar mandibular shape differences
were found in the comparison between RME/BB and CG groups
(PC1: 27%, PC2: 17.3%, PC3: 12.1%, PC4: 9%, PC5: 6.9%) as
represented by Figure 6 and Supplementary Figure 4a–c.
No statically significant morphologic mandibular changes were
found when comparing QH/C and CG groups (10 000 permutations;
P  =  0.67; PC1: 27%, PC2: 20.4%, PC3: 16.5%, PC4: 7.7%, PC5:
6.1%). However, a slight change in mandibular ramus position was
assessed in the QH/C group (Figure 7 and Supplementary Figure 5a–c).

Discussion
The purpose of the present study was to evaluate the morphological
changes of the mandible at the end of growth, in OB treated subjects
when compared with an untreated CG by using conventional ceph-
alometric and GMM.
The CG matched the treated groups for negative overbite at Figure 6. Morphological mandibular comparison between RME/BB (blue)
T1, skeletal vertical dysplasia, chronologic age, gender distribution, and CG (red).
648
Figure 7.  Morphological mandibular comparison between QH/C (yellow) and
CG (red).
skeletal maturation at the various time periods, and duration of
intervals. Although historical CGs might have some limitations (39),
the use of historical controls was due to ethical concerns to leave
children with anterior OB untreated to collect a contemporary CG.
OB malocclusion is considered one of the most difficult ortho-
dontic problems to correct because it appears as a result of the inter-
action of numerous aetiological factors (40). It is one of the most
challenging malocclusions to treat because of the high frequency of
relapse. Traditionally, occlusal and craniofacial characteristics of
growing subjects with anterior OB have been studied in the sagittal
and vertical planes with conventional cephalometric analysis on lat-
eral cephalograms. Nowadays, 3D technology trough GMM allows
to show morphological changes in their complexity, in a more ef-
fective way than traditional linear measurements (41).
In literature there are few studies (42,43) that analysed anterior
OB patients by means of GMM. Krey et al. (42) illustrated the skel-
etal morphology of OB adult subjects against the background of sa-
gittal jaw relationships on the basis of lateral cephalograms. They
observed that all skeletal OB subjects have mandibular ramus com-
pressed due to growth deficit. However, marked differences were de-
tected in terms of vertical maxillary development among untreated
OB subjects. Therefore, this different morphological pattern of the
maxilla, should be taken into consideration during individual aeti-
ology assessment and treatment planning. Freudenthaler et al. (43)
evaluated the role of craniofacial shape in different malocclusions in
growing and adult untreated subjects by application of GMM to a
set of two-dimensional landmarks obtained from lateral skull radio-
graphs. They found that OB subjects presented the maxilla inclined
upward and the mandible downward.
To our knowledge, this is the first attempt to investigate the
mandibular shape response after two distinctive strategies of early
treatment to correct anterior OB with different aetiology at the long
term. Diagnostic criteria for anterior OB should be standardized
and the interventions should be tested to each type of anterior OB:
skeletal or anterior OB due to sucking habit. Indeed, the initial OB
European Journal of Orthodontics, 2020, Vol. 42, No. 6
group was divided in two subgroups according to the presence or
absence of prolonged sucking habits. The limitation of the study was
that the division of OB in two subgroups was based on referral of
thumb-sucking habits without assessing the entity of thumb sucking.
Another limitation is the absence of information regarding to trans-
verse dimension of untreated subjects, since they were derived from
an historical CG with only latero-lateral cephalograms available.
Consequently, the specific interceptive therapy (i.e. RME/BB
or QH/C) aimed to influence the growth of different skeletal struc-
tures. Mucedero et al. (20) showed that RME/BB protocol exhibited
reduced extrusion of maxillary and mandibular molars and, conse-
quently, a significant improvement in the vertical skeletal dimension
when compared with untreated OB subjects. As reported by several
authors (5–10) in OB malocclusion the ramus and the body of the
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mandible are shorter. Therefore, in long-face syndrome can be observe
arrested growth, not in the front part of the face where the disturbance
occurs, but rather in the back part of the mandible and in the ramus.
In the present study, at long-term follow-up (T2), RME/BB sub-
jects showed a decrease of the Condax^MP angle in RME/BB group
when compared to QH/C and CG. Contemporarily in GMM, PC1
showed significant changes within the observed growth period. The
mandibular ramus increased in height in RME/BB group with ten-
dency to the counterclockwise rotation of the mandible when con-
fronted to CG and QH/C. The mandibular shape changes were not
primarily located at the gonion but along the mandibular ramus. In
the present study, mandibular ramus morphology played a larger
role in individuals with no sucking OB. Orthopaedic strategy (RME/
BB) resulted in reduced steepness of the mandibular and occlusal
planes contributing to the correction of skeletal vertical dysplasia as
a consequent elongation of the mandibular ramus.
On the contrary, QH/C protocol did not affect the mandibular
morphology, in agreement with previous studies (3) that demonstrated
a clinically significant downward rotation of the palatal plane without
mandibular changes when confronted to CG. The effect of QH/C is to
allow teeth to develop in their proper relation closing the bite.
Conclusion
• GMM is a useful tool to visually illustrate and describe man-
dibular shape changes in children with OB malocclusion after
treatment.
• RME/BB subjects showed significant changes in the vertical
orientation of the mandibular ramus with a counterclockwise ro-
tation tendency when compared with QH/C and CG subjects.
• In subjects treated by RME/BB, elongation of the mandibular
ramus contributed to OB correction resulted in reduced steep-
ness of the mandibular and occlusal planes.
Supplementary material
Supplementary data are available at European Journal of
Orthodontics online.
Conflicts of interest
None to declare.
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