Extraoral Implants in the Rehabilitation of Craniofacial Defects: Implant and Prosthesis Survival Rates and Peri-Implant Soft Tissue Evaluation

Purpose: Few reports have evaluated cumulative survival rates of extraoral rehabilitation and peri-implant soft tissue reaction at long-term follow-up. The objective of this study was to evaluate implant and prosthesis survival rates and the soft tissue reactions around the extraoral implants used to support craniofacial prostheses. Materials and Methods: A retrospective study was performed of patients who received implants for craniofacial rehabilitation from 2003 to 2010. Two outcome variables were considered: implant and prosthetic success. The following predictor variables were recorded: gender, age, implant placement location, number and size of implants, irradiation status in the treated field, date of prosthesis delivery, soft tissue response, and date of last follow-up. A statistical model was used to estimate survival rates and associated confidence intervals. We randomly selected 1 implant per patient for analysis. Data were analyzed using the Kaplan-Meier method and log-rank test to compare survival curves. Results: A total of 150 titanium implants were placed in 56 patients. The 2-year overall implant survival rates were 94.1% for auricular implants, 90.9% for nasal implants, 100% for orbital implants, and 100% for complex midfacial implants (P = .585). The implant survival rates were 100% for implants placed in irradiated patients and 94.4% for those placed in nonirradiated patients (P = .324). The 2-year overall prosthesis survival rates were 100% for auricular implants, 90.0% for nasal implants, 92.3% for orbital implants, and 100% for complex midfacial implants (P = .363). The evaluation of the peri-implant soft tissue response showed that 15 patients (26.7%) had a grade 0 soft tissue reaction, 30 (53.5%) had grade 1, 6 (10.7%) had grade 2, and 5 (8.9%) had grade 3. Conclusions: From this study, it was concluded that craniofacial rehabilitation with extraoral implants is a safe, reliable, and predictable method to restore the patient's normal appearance. (C) 2012 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 70:1551-1557, 2012

Tests of one Brazilian facial reconstruction method using three soft tissue depth sets and familiar assessors

Facial reconstruction is a method that seeks to recreate a person's facial appearance from his/her skull. This technique can be the last resource used in a forensic investigation, when identification techniques such as DNA analysis, dental records, fingerprints and radiographic comparison cannot be used to identify a body or skeletal remains. To perform facial reconstruction, the data of facial soft tissue thickness are necessary. Scientific literature has described differences in the thickness of facial soft tissue between ethnic groups. There are different databases of soft tissue thickness published in the scientific literature. There are no literature records of facial reconstruction works carried out with data of soft tissues obtained from samples of Brazilian subjects. There are also no reports of digital forensic facial reconstruction performed in Brazil. There are two databases of soft tissue thickness published for the Brazilian population: one obtained from measurements performed in fresh cadavers (fresh cadavers' pattern), and another from measurements using magnetic resonance imaging (Magnetic Resonance pattern). This study aims to perform three different characterized digital forensic facial reconstructions (with hair, eyelashes and eyebrows) of a Brazilian subject (based on an international pattern and two Brazilian patterns for soft facial tissue thickness), and evaluate the digital forensic facial reconstructions comparing them to photos of the individual and other nine subjects. The DICOM data of the Computed Tomography (CT) donated by a volunteer were converted into stereolitography (STL) files and used for the creation of the digital facial reconstructions. Once the three reconstructions were performed, they were compared to photographs of the subject who had the face reconstructed and nine other subjects. Thirty examiners participated in this recognition process. The target subject was recognized by 26.67% of the examiners in the reconstruction performed with the Brazilian Magnetic Resonance Pattern, 23.33% in the reconstruction performed with the Brazilian Fresh Cadavers Pattern and 20.00% in the reconstruction performed with the International Pattern, in which the target-subject was the most recognized subject in the first two patterns. The rate of correct recognitions of the target subject indicate that the digital forensic facial reconstruction, conducted with parameters used in this study, may be a useful tool. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Evidence of 5-aminolevulinic acid (ALA) penetration increase due to microdrilling in soft tissue using femtosecond laser ablation

Photodynamic therapy (PDT) is a therapeutic technique mainly applied to the treatment of malignant and pre-malignant lesions, which induces cell death by the combined effect of a photosensitizer, irradiation in a proper wavelength, and molecular oxygen. One of the main limitations of PDT using 5-aminolevulinic acid (ALA) is the superficial volume of treatment, mainly due to the limited penetration of topical photosensitization. In this context, the present study investigates if a laser micromachining producing microchannels on the tissue surface could improve ALA penetration and result in an increase in the treatment depth. The laser micromachining under femtosecond regime was performed on the tissue surface of rat livers. Conventional PDT was applied and the induced depth of necrosis with or without laser micromachining was compared. The results showed an increase of more than 20% in the depth of necrosis when the femtosecond laser micromachining was performed before the treatment with the PDT.

Prognostication of Soft Tissue Sarcomas Based on Chromosome 17q Gene and Protein Status: Evaluation of TOP2A, HER-2/neu, and Survivin

Topoisomerase 2 alpha (), HER-2/ and are genes that lie on chromosome 17 and correlate with the prognosis and prediction of target-driven therapy against tumors. In a previous study, we showed that TOP2A transcripts levels were significantly higher in soft tissue sarcomas (STS) than in benign tumors and desmoid-type fibromatoses (FM). Because these genes have been insufficiently examined in STS, we aimed to identify alterations in TOP2A and HER-2 expression by fluorescent in situ hybridization and immunohistochemistry, as well as that of survivin, and correlate them with clinicopathologic findings to assess their prognostic value. Eighteen FM and 244 STS were included. Fluorescent in situ hybridization and immunohistochemistry were performed on a tissue microarray. TOP2A and survivin were more highly expressed in sarcomas than in FM. TOP2A was an independent predictor of an unfavorable prognosis; it was combined with formerly established prognostic factors (primarily histologic grade and tumor size at diagnosis) to create a prognostic index that evaluated overall survival. Gene amplification/polysomy (13%) did not correlate with protein overexpression. Survivin and HER-2 expression were not associated with patient outcomes. These findings might become valuable in the management of patients with STS and possibly in the prospective evaluation of responses to new target-driven therapies.

Soft tissue profile changes after rapid maxillary expansion with a bonded expander

The aim of this study was to evaluate the short-and long-term treatment effects of rapid maxillary expansion (RME) on the soft tissue facial profile of subjects treated with a modified acrylic-hyrax device. The sample comprised 10 males and 10 females in the mixed dentition. Their average age was 9.3 years +/- 10 months pre-treatment (T1), with a narrow maxilla and posterior crossbite, treated with a modified fixed maxillary expander with an occlusal splint. Lateral cephalometric radiographs obtained at T1, immediately post-expansion (T2), and after retention (T3) were used to determine possible changes in the soft tissue facial profile. The means and standard deviations for linear and angular cephalometric measurements were analysed statistically using analysis of variance and Tukey's test (alpha = 0.05). The measurements at T2 differed significantly from those at T1 and T3. However, RME did not produce any statistically significant alteration (P > 0.05) in the soft tissue profile for any of the cephalometric landmarks evaluated when compared at T1 and T3. The use of a fixed expander associated with an occlusal splint did not cause significant alterations in the soft tissue facial profile at T3. This modified device is effective for preventing the adverse vertical effects of RME such as an increase anterior face height in patients with a crossbite.

Comparative study by computed radiography, histology, and scanning electron microscopy of the articular cartilage of normal goats and in chronic infection with caprine arthritis-encephalitis virus

In the northeast of Brazil, caprine arthritis-encephalitis (CAE) is one of the key reasons for herd productivity decreasing that result in considerable economic losses. A comparative study was carried out using computed radiography (CR), histological analysis (HA), and scanning electronic microscopy (SEM) of the joints of CAE infected and normal goats. Humerus head surface of positive animals presented reduced joint space, increased bone density, and signs of degenerative joint disease (DJD). The carpal joint presented no morphological alterations in CR in any of the animals studied. Tarsus joint was the most affected, characterized by severe DJD, absence of joint space, increased periarticular soft tissue density, edema, and bone sclerosis. Histological analysis showed chronic tissue lesions, complete loss of the surface zone, absence of proteoglycans in the transition and radial zones and destruction of the cartilage surface in the CAE positive animals. Analysis by SEM showed ulcerated lesions with irregular and folded patterns on the joint surface that distinguished the limits between areas of normal and affected cartilage. The morphological study of the joints of normal and CAE positive goats deepened understanding of the alteration in the tissue bioarchitecture of the most affected joints. The SEM finding sustained previous histological reports, similar to those found for rheumatoid arthritis, suggesting that the goat infected with CAE can be considered as a potential model for research in this area.

Oral myiasis in an elderly patient

Background: Myiasis is the invasion of living tissue of humans and other mammals by eggs or maggots of flies of the order of Diptera. It occurs mainly in the Tropics and is associated with inadequate public and personal hygiene. Oral myiases in an older man appears to be rare. Objective: To relate a case of oral myiases in a debilitated older man treated by mechanical removal of the maggots, identifying the adult insect that caused the infestation. Methods: The diagnosis of oral myiasis was established by the clinical examination and it was detected that the infestation involved only soft tissue and the sinus cavity. The patient was submitted to two mechanical removal of the visible maggots. Results: Total of 110 maggots was removed from the oral cavity of the patient and adult insects was identified as belonging to the Calliphoridae Family, Cochliomyia hominivorax species. The patient died two days after the second procedure by severe systemic complications. Conclusions: The mechanic removal and the identification of the maggots must be adopted as soon as possible to prevent further tissue damage and bacterial infection in cases of oral myiasis. Special attention should be given to the debilitated old patients that are particularly susceptible to oral myiasis infestation.

Prenatal detection and postnatal management of an intranasal glioma

Nasal gliomas are rare benign congenital midline tumors composed of heterotopic neuroglial tissue. They have potential for intracranial extension through a bony defect in the skull base. Neuroimaging is essential for identifying nasal lesions and for determining their exact location and any possible intracranial extension. Computed tomography is often the initial imaging study obtained because it provides good visualization of the bony landmarks of the skull base; it is not, however, well suited for soft tissue imaging. Magnetic resonance imaging has better soft tissue resolution and may be the best initial study in patients seen early in life because the anterior skull base consists of an unossified cartilage and may falsely appear as if there is a bony dehiscence on computed tomography. A frontal craniotomy approach is recommended if intracranial extension is identified, followed by a transnasal endoscopic approach for intranasal glioma. A case is presented of a huge fetal facial mass that was shown by ultrasound that protruded through the left nostril at 33 weeks of gestation. Computed tomography of the neonate suggested a transethmoidal encephalocele. Magnetic resonance imaging showed a huge mass occupying the nasopharynx and the nasal cavity and protruding externally to the face but ruled out bony discontinuity in the skull base and, therefore, any intracranial connection. The infant underwent an endoscopic resection of the mass via oral and nasal routes and pathologic examination revealed intranasal glioma. (C) 2012 Elsevier Inc. All rights reserved.

FGFR4 Profile as a Prognostic Marker in Squamous Cell Carcinoma of the Mouth and Oropharynx

Background: Fibroblast growth factor receptor 4 (FGFR4) is a member of a receptor tyrosine kinase family of enzymes involved in cell cycle control and proliferation. A common single nucleotide polymorphism (SNP) Gly388Arg variant has been associated with increased tumor cell motility and progression of breast cancer, head and neck cancer and soft tissue sarcomas. The present study evaluated the prognostic significance of FGFR4 in oral and oropharynx carcinomas, finding an association of FGFR4 expression and Gly388Arg genotype with tumor onset and prognosis. Patients and Methods: DNA from peripheral blood of 122 patients with oral and oropharyngeal squamous cell carcinomas was used to determine FGFR4 genotype by PCR-RFLP. Protein expression was assessed by immunohistochemistry (IHC) on paraffin-embedded tissue microarrays. Results: Presence of allele Arg388 was associated with lymphatic embolization and with disease related premature death. In addition, FGFR4 low expression was related with lymph node positivity and premature relapse of disease, as well as disease related death. Conclusion: Our results propose FGFR4 profile, measured by the Gly388Arg genotype and expression, as a novel marker of prognosis in squamous cell carcinoma of the mouth and oropharynx.

Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate.

Predicting dysthyroid optic neuropathy using computed tomography volumetric analyses of orbital structures

OBJECTIVE: To evaluate the ability of orbital apex crowding volume measurements calculated with multidetector-computed tomography to detect dysthyroid optic neuropathy. METHODS: Ninety-three patients with Graves' orbitopathy were studied prospectively. All of the patients underwent a complete neuro-ophthalmic examination and computed tomography scanning. Volumetric measurements were calculated from axial and coronal contiguous sections using a dedicated workstation. Orbital fat and muscle volume were estimated on the basis of their attenuation values (in Hounsfield units) using measurements from the anterior orbital rim to the optic foramen. Two indexes of orbital muscle crowding were calculated: i) the volumetric crowding index, which is the ratio between soft tissue (mainly extraocular muscles) and orbital fat volume and is based on axial scans of the entire orbit; and ii) the volumetric orbital apex crowding index, which is the ratio between the extraocular muscles and orbital fat volume and is based on coronal scans of the orbital apex. Two groups of orbits (with and without dysthyroid optic neuropathy) were compared. RESULTS: One hundred and two orbits of 61 patients with Graves' orbitopathy met the inclusion criteria and were analyzed. Forty-one orbits were diagnosed with Graves' orbitopathy, and 61 orbits did not have optic neuropathy. The two groups of orbits differed significantly with regard to both of the volumetric indexes (p<0.001). Although both indexes had good discrimination ability, the volumetric orbital apex crowding index yielded the best results with 92% sensitivity, 86% specificity, 81%/94% positive/negative predictive value and 88% accuracy at a cutoff of 4.14. CONCLUSION: This study found that the orbital volumetric crowding index was a more effective predictor of dysthyroid optic neuropathy than previously described computed tomography indexes were.

Short implants (6 mm) installed immediately into extraction sockets: An experimental study in dogs

Aim: To evaluate the effect of implant length (6 mm vs. 11 mm) on osseointegration (bone-toimplant contact) of implants installed into sockets immediately after tooth extraction. Material and methods: In six Labrador dogs, the pulp tissue of the mesial roots of P-3(3) was removed and the root canals were filled. Flaps were elevated bilaterally, the premolars hemisectioned and the distal roots removed. Recipient sites were prepared in the distal alveolus and a 6 mm or an 11 mm long implant was installed at the test and control sites, respectively. Non-submerged healing was allowed. After 4 months of healing, block sections of the implant sites were obtained for histological processing and peri-implant tissue assessment. Results: No statistically significant differences were found between test and control sites both for hard and soft tissue parameters. The bone-to-implant contact evaluated at the apical region of the implants was similar as well. Although not statistically significant, the location of the top of the bony crest at the buccal aspect was more apical in relation to the implant shoulder at the test compared with the control sites (2.0 +/- 1.4 and 1.2 +/- 1.1 mm, respectively). Conclusions: Shorter implants (6 mm) present with equal osseointegration than do longer implants (11 mm).

Inward-Inclined Implant Platform for the Amplified Platform-Switching Concept: 18-Month Follow-up Report of a Prospective Randomized Matched-Pair Controlled Trial

Purpose: This prospective randomized matched-pair controlled trial aimed to evaluate marginal bone levels and soft tissue alterations at implants restored according to the platform-switching concept with a new inward-inclined platform and compare them with external-hexagon implants. Materials and Methods: Traditional external-hexagon (control group) implants and inward-inclined platform implants (test group), all with the same implant body geometry and 13 mm in length, were inserted in a standardized manner in the posterior maxillae of 40 patients. Radiographic bone levels were measured by two independent examiners after 6, 12, and 18 months of prosthetic loading. Buccal soft tissue height was measured at the time of abutment connection and 18 months later. Results: After 18 months of loading, all 80 implants were clinically osseointegrated in the 40 participating patients. Radiographic evaluation showed mean bone losses of 0.5 +/- 0.1 mm (range, 0.3 to 0.7 mm) and 1.6 +/- 0.3 mm (range, 1.1 to 2.2 mm) for test and control implants, respectively. Soft tissue height showed a significant mean decrease of 2.4 mm in the control group, compared to 0.6 mm around the test implants. Conclusions: After 18 months, significantly greater bone loss was observed at implants restored according to the conventional external-hexagon protocol compared to the platform-switching concept. In addition, decreased soft tissue height was associated with the external-hexagon implants versus the platform-switched implants. INT J ORAL MAXILLOFAC IMPLANTS 2012;27:927-934.

Transoral Submucosal Resection of the Inferior Turbinate A Novel Approach to Functional Rhinoplasty

Background: In the presence of turbinate dysfunction, an inferior turbinectomy for persistent hypertrophy of bone and/or mucosa may be performed. We sought to explore anatomic feasibility of a transoral turbinectomy. Methods: After transoral inferior turbinectomy in 12 cadavers, average distances from the external nasal valve to inferior turbinate and from pyriform aperture to inferior turbinate were compared. Average "area of access" was calculated. Preoperative and postoperative nasal length, tip projection, and alar-base width were also compared. Results: Average distance from external nasal valve to inferior turbinate was 32.4 mm. Average distance from aperture to inferior turbinate was 2.4 mm (P < 0.0001). Average "areas of access" to nasal vault through the external nasal valve and mouth were 183.9 mm(2) and 243.6 mm(2) (P = 0.07), respectively. Conclusions: The transoral approach provides a larger "area of access" to the turbinate, a statistically significant reduction of distance to target, no postoperative changes in nasal soft tissue, and easier instrumentation.

Repression of osteocyte Wnt/beta-catenin signaling is an early event in the progression of renal osteodystrophy

Chronic kidney diseasemineral bone disorder (CKD-MBD) is defined by abnormalities in mineral and hormone metabolism, bone histomorphometric changes, and/or the presence of soft-tissue calcification. Emerging evidence suggests that features of CKD-MBD may occur early in disease progression and are associated with changes in osteocyte function. To identify early changes in bone, we utilized the jck mouse, a genetic model of polycystic kidney disease that exhibits progressive renal disease. At 6 weeks of age, jck mice have normal renal function and no evidence of bone disease but exhibit continual decline in renal function and death by 20 weeks of age, when approximately 40% to 60% of them have vascular calcification. Temporal changes in serum parameters were identified in jck relative to wild-type mice from 6 through 18 weeks of age and were subsequently shown to largely mirror serum changes commonly associated with clinical CKD-MBD. Bone histomorphometry revealed progressive changes associated with increased osteoclast activity and elevated bone formation relative to wild-type mice. To capture the early molecular and cellular events in the progression of CKD-MBD we examined cell-specific pathways associated with bone remodeling at the protein and/or gene expression level. Importantly, a steady increase in the number of cells expressing phosphor-Ser33/37-beta-catenin was observed both in mouse and human bones. Overall repression of Wnt/beta-catenin signaling within osteocytes occurred in conjunction with increased expression of Wnt antagonists (SOST and sFRP4) and genes associated with osteoclast activity, including receptor activator of NF-?B ligand (RANKL). The resulting increase in the RANKL/osteoprotegerin (OPG) ratio correlated with increased osteoclast activity. In late-stage disease, an apparent repression of genes associated with osteoblast function was observed. These data confirm that jck mice develop progressive biochemical changes in CKD-MBD and suggest that repression of the Wnt/beta-catenin pathway is involved in the pathogenesis of renal osteodystrophy. (C) 2012 American Society for Bone and Mineral Research.