Timing of Alveolar Bone Grafting Determines Different Outcomes in Patients With Unilateral Cleft Palate

The objective of the current study was to assess the outcome of the alveolar bone grafting (ABG) in patients with cleft palate. Thirty-one patients with complete unilateral cleft lip and palate were prospectively divided into 2 groups according to the timing of surgery: (1) secondary ABG (SABG), undertaken during mixed dentition (n = 16); and (2) tertiary ABG (TABG), undertaken during permanent dentition (n = 15). Septum height was assessed using cone beam computed tomography in 3 views (buccal, intermediate, palatal) and classified according to the modified Bergland Index, which scores the results into 5 types according to the height of the neoformed bone septum (excellent: septum with a normal height; good: septum with minor deficiency; regular: marginal defect of >25% of the root length; bad: bone deficiency on the nasal aspect; and failure). In the SABG group, 6 to 12 months postoperatively, 75% of the patients were classified as having excellent/good conditions and 25% as having regular/bad conditions. No patients were observed as having failure conditions. In the TABG group, 53% of the patients were classified as having excellent/good, 21% were classified as having regular/bad conditions, and 26% were classified as having failure conditions. Significantly better outcomes were observed for the SABG group when compared with the TABG group. In conclusion, the age at which ABG is performed is a factor that impacts on the surgical outcome. Specifically, increasing age is associated with worse outcomes.

Evaluation of a Maxillary Sinus Floor Augmentation in the Presence of a Large Antral Pseudocyst

Sinus floor augmentation has been established as a predictable technique to overcome maxillary bone loss. Antral cystic lesions may lead to intrasurgical complications and should be accurately diagnosed. However, antral pseudocysts have recently been described not to be contraindicated for sinus-grafting procedures. The current article sought to report clinical, cone beam computed tomographic, and histologic results of a maxillary sinus floor augmentation, performed with piezoelectric surgery, in the presence of a large antral pseudocyst. Success of graft maturation was confirmed with histologic analysis, which also indicated the absence of inflammatory infiltration in the tissue evaluated. On the basis of our findings, it is possible to perform a predictable treatment based on sinus floor augmentation in the presence of antral pseudocysts. Graft maturation can also be achieved 6 months after sinus-lifting surgeries.

La radioterapia e le tecniche I.G.R.T. applicate

L'elaborato espone l'iter di un paziente nel reparto di radioterapia e descrive l'evoluzione delle immagini radioterapiche dai portal film alle Cone Beam Computer Tomography. Inoltre espone i vari standard e protocolli usati per archiviare e trasmettere le immagini digitali precedentemente descritte.

Comparison of actual surgical outcomes and 3-dimensional surgical simulations

PURPOSE: The advent of imaging software programs has proved to be useful for diagnosis, treatment planning, and outcome measurement, but precision of 3-dimensional (3D) surgical simulation still needs to be tested. This study was conducted to determine whether the virtual surgery performed on 3D models constructed from cone-beam computed tomography (CBCT) can correctly simulate the actual surgical outcome and to validate the ability of this emerging technology to recreate the orthognathic surgery hard tissue movements in 3 translational and 3 rotational planes of space. MATERIALS AND METHODS: Construction of pre- and postsurgery 3D models from CBCTs of 14 patients who had combined maxillary advancement and mandibular setback surgery and 6 patients who had 1-piece maxillary advancement surgery was performed. The postsurgery and virtually simulated surgery 3D models were registered at the cranial base to quantify differences between simulated and actual surgery models. Hotelling t tests were used to assess the differences between simulated and actual surgical outcomes. RESULTS: For all anatomic regions of interest, there was no statistically significant difference between the simulated and the actual surgical models. The right lateral ramus was the only region that showed a statistically significant, but small difference when comparing 2- and 1-jaw surgeries. CONCLUSIONS: Virtual surgical methods were reliably reproduced. Oral surgery residents could benefit from virtual surgical training. Computer simulation has the potential to increase predictability in the operating room.

Der Retromolarkanal bzw. das Foramen retromolare. Übersicht und Fallbericht

A 19-year old female patient was referred for removal of her wisdom teeth. The panoramic radiograph showed bilateral retromolar canals in the mandible. Since the retromolar canal is neglected in anatomical textbooks and is rarely documented in scientific publications, the case prompted us to perform further diagnostic examinations with informed consent by the patient. A limited cone beam computed tomography was made and, during the surgical removal of the patient's lower right wisdom tooth, a biopsy of the soft tissue bundle emerging from the retromolar foramen was taken. In accordance with the literature, the histology revealed myelinated nerve fibers, small arteries and venules. The limited data available in the literature about the retromolar canal report that this bony canal may convey an aberrant buccal nerve. In addition, sensory nerve fibers entering the retromolar canal from above and branching to the mandibular molars may evade a block anesthesia at the mandibular foramen. These rare anatomic features may explain why the elements of the retromolar canal account for failures of mandibular block anesthesia or postsurgical sensitivity changes in the supply area of the buccal nerve.

Severe complication of a bonded mandibular lingual retainer

Bonding a flexible spiral wire retainer to the lingual surfaces of all 6 anterior mandibular teeth is a commonly used type of retention. Complications are rare but can be serious enough to produce biologic damage. This article presents a serious complication of a lingual flexible spiral wire retainer. Four years after the orthodontic treatment, a 20-year-old man sought treatment for a broken flexible spiral wire retainer. The clinical examination showed about 35° of buccal root torque of that tooth. A cone-beam computed tomography image showed that the root and the apex of the tooth were almost completely out of the bone on its buccal side. Surprisingly, the tooth's vitality was preserved. The tooth was moved back, nearly to its original position; clinically, only a gingival recession remained. Orthodontists and dentists should be aware of possible complications of bonded retainers. Patients should be clearly informed how to detect problems at an early stage.

Oral mucosal morphea: a new variant

Morphea is a cutaneous disorder characterized by an excessive collagen deposition. While in almost all cases the sclerosing process exclusively affects the skin, there are anecdotal cases in which associated mucosal involvement has been described. We here report the case of a woman developing a whitish indurated plaque over the left upper vestibular mucosa and hard palate leading to dental mobility and exposure of the roots of several teeth. Cone beam computed tomography of the left maxilla showed bone resorption involving the upper cuspid to the second molar region with widened periodontal ligament spaces, while light microscopy studies demonstrated epithelial atrophy and fibrosis of the dermis extending into the submucosa with hyalinization of subepithelial collagen. Our observation expands the spectrum of clinical presentations of morphea and provides the first example of isolated oral morphea. Its recognition is important to avoid significant local complications.

E.A.O. guidelines for the use of diagnostic imaging in implant dentistry 2011. A consensus workshop organized by the European Association for Osseointegration at the Medical University of Warsaw

Diagnostics imaging is an essential component of patient selection and treatment planning in oral rehabilitation by means of osseointegrated implants. In 2002, the EAO produced and published guidelines on the use of diagnostic imaging in implant dentistry. Since that time, there have been significant developments in both the application of cone beam computed tomography as well as in the range of surgical and prosthetic applications that can potentially benefit from its use. However, medical exposure to ionizing radiation must always be justified and result in a net benefit to the patient. The as low a dose as is reasonably achievable principle must also be applied taking into account any alternative techniques that might achieve the same objectives. This paper reports on current EAO recommendations arising from a consensus meeting held at the Medical University of Warsaw (2011) to update these guidelines. Radiological considerations are detailed, including justification and optimization, with a special emphasis on the obligations that arise for those who prescribe or undertake such investigations. The paper pays special attention to clinical indications and radiographic diagnostic considerations as well as to future developments and trends.

Hip2Norm: an object-oriented cross-platform program for 3D analysis of hip joint morphology using 2D pelvic radiographs

We developed an object-oriented cross-platform program to perform three-dimensional (3D) analysis of hip joint morphology using two-dimensional (2D) anteroposterior (AP) pelvic radiographs. Landmarks extracted from 2D AP pelvic radiographs and optionally an additional lateral pelvic X-ray were combined with a cone beam projection model to reconstruct 3D hip joints. Since individual pelvic orientation can vary considerably, a method for standardizing pelvic orientation was implemented to determine the absolute tilt/rotation. The evaluation of anatomically morphologic differences was achieved by reconstructing the projected acetabular rim and the measured hip parameters as if obtained in a standardized neutral orientation. The program had been successfully used to interactively objectify acetabular version in hips with femoro-acetabular impingement or developmental dysplasia. Hip(2)Norm is written in object-oriented programming language C++ using cross-platform software Qt (TrollTech, Oslo, Norway) for graphical user interface (GUI) and is transportable to any platform.

Loss of pulp sensitivity and pain as the first symptoms of a Ewing's sarcoma in the right maxillary sinus and alveolar process: report of a case

This case report describes the diagnosis and treatment of a Ewing's sarcoma in the right maxillary sinus and alveolar bone of a 19-year-old female patient. The first clinical symptoms were a loss of sensitivity of the premolars and first molar in the right maxilla and acute pain located in the area of these teeth. Initially, the referring dentist had treated these findings as an acute apical periodontitis with root canal medication. Because swellings on the palatal and buccal aspects of the teeth occurred and could not be treated with incision and drainage, the dentist referred the patient. Cone-beam computed tomography revealed a proliferation of soft tissue in the right maxillary sinus, with a radiopaque material at the tip of the mesiobuccal root of the first molar and resorptive signs of the mesiobuccal and distobuccal roots of the first molar. The palatal cortical bone of the right alveolar process seemed to be intact. After explorative surgery with biopsies from the buccal, palatal, and sinus proliferation areas, the pathologist diagnosed the lesion as a Ewing's sarcoma. Treatment of the patient consisted of initial chemotherapy, hemimaxillectomy, and postsurgical chemoradiotherapy.

[Interradicular course of the inferior alveolar nerve at the mandibular right third molar and monostotic fibrous dysplasia affecting the mandibular left third molar in the same patient. A case report]

To minimize the risk of intraoperative complications, a comprehensive radiological diagnostic work-up should be a routine procedure in oral surgery. This is especially true concerning possible damage to the inferior alveolar nerve during surgical removal of the third molars. The course and location of the nerve are best assessed when evaluating panoramic view images or cone beam CTs. The following case report demonstrates and discusses the importance of a thorough radiological evaluation before surgery, the problems raised by an interradicular course of the inferior alveolar nerve, and the finding of a monostotic fibrous dyplasia in the same patient.

Anterior Stafne's bone cavity mimicking a periapical lesion of endodontic origin: report of two cases

INTRODUCTION: This report of 2 cases describes the diagnostic procedures used to identify 2 Stafne's bone cavities (SBC) found in unusually anterior locations in the mandible, both mimicking periapical lesions of endodontic origin. METHODS: In the first patient, a 47-year-old man, an SBC was diagnosed in the area of teeth #27, 28, and 29. In the second patient, a 62-year-old man, the SBC was a fortuitous finding, because this patient was referred for dental implant therapy. RESULTS: In both cases, the final diagnosis was achieved by using limited cone beam computed tomography (CBCT) and magnetic resonance imaging (MRI). In both patients, the lingual bone cavity was found to be occupied by accessory salivary gland tissue. CONCLUSIONS: The combination of CBCT and MRI as noninvasive diagnostic techniques seems ideal to avoid surgical explorations, incisional biopsies, or enucleations of the lesion for diagnostic purposes.

Long-term stability of early implant placement with contour augmentation

In this prospective case series study, 20 patients with an implant-borne single crown following early implant placement with simultaneous contour augmentation were followed for 6 years. Clinical, radiologic, and esthetic parameters were assessed. In addition, cone beam computed tomography (CBCT) was used at 6 years to examine the facial bone wall. During the study period, all 20 implants were successfully integrated, and the clinical parameters remained stable over time. Pleasing esthetic outcomes were noted, as assessed by the pink esthetic scores. None of the implants developed mucosal recession of 1 mm or more. The periapical radiographs yielded stable peri-implant bone levels, with a mean DIB of 0.44 mm at 6 years. The CBCT scans showed that all 20 implants had a detectable facial bone wall at 6 years, with a mean thickness of around 1.9 mm. In summary, this prospective case series study demonstrated stable peri-implant hard and soft tissues for all 20 implants, and pleasing esthetic outcomes overall. The follow-up of 6 years confirmed that the risk for mucosal recession is low with early implant placement. In addition, contour augmentation with guided bone regeneration (GBR) was able to establish and maintain a facial bone wall in all 20 patients.

Long-term stability of contour augmentation with early implant placement following single tooth extraction in the esthetic zone: a prospective, cross-sectional study in 41 patients with a 5- to 9-year follow-up

BACKGROUND Early implant placement with simultaneous contour augmentation is documented with short- and medium-term studies. The long-term stability of contour augmentation is uncertain. METHODS In this prospective, cross-sectional study, 41 patients with an implant-borne single crown were examined twice, in 2006 and 2010. Clinical, radiologic, and esthetic parameters were assessed at both examinations. In addition, a cone beam computed tomographic (CBCT) image was obtained during the second examination to assess the dimensions of the facial bone wall. RESULTS All 41 implants demonstrated ankylotic stability without signs of peri-implant infection at both examinations. The clinical parameters remained stable over time. Satisfactory esthetic outcomes were noted, as assessed by the pink and white esthetic score (PES/WES) indices. Overall, the PES scores were slightly higher than the WES scores. None of the implants developed mucosal recession over time, as confirmed by values of the distance between implant shoulder and mucosal margin and cast measurements. The periapical radiographs yielded stable peri-implant bone levels, with a mean distance between implant shoulder and first visible bone-implant contact value of 2.18 mm. The CBCT analysis demonstrated a mean thickness of the facial bone wall ≈2.2 mm. In two implants (4.9%) no facial bone wall was detectable radiographically. CONCLUSIONS This prospective cross-sectional study demonstrates stable peri-implant hard and soft tissues for all 41 implants examined and satisfactory esthetic outcomes overall. The follow-up of 5 to 9 years confirmed again that the risk for mucosal recession is low with early implant placement. In addition, contour augmentation with guided bone regeneration was able to establish and maintain a facial bone wall in 95% of patients.

Ridge alterations post-extraction in the esthetic zone: a 3D analysis with CBCT

Dimensional alterations of the facial bone wall following tooth extractions in the esthetic zone have a profound effect on treatment outcomes. This prospective study in 39 patients is the first to investigate three-dimensional (3D) alterations of facial bone in the esthetic zone during the initial 8 wks following flapless tooth extraction. A novel 3D analysis was carried out, based on 2 consecutive cone beam computed tomographies (CBCTs). A risk zone for significant bone resorption was identified in central areas, whereas proximal areas yielded only minor changes. Correlation analysis identified a facial bone wall thickness of ≤ 1 mm as a critical factor associated with the extent of bone resorption. Thin-wall phenotypes displayed pronounced vertical bone resorption, with a median bone loss of 7.5 mm, as compared with thick-wall phenotypes, which decreased by only 1.1 mm. For the first time, 3D analysis has allowed for documentation of dimensional alterations of the facial bone wall in the esthetic zone of humans following extraction. It also characterized a risk zone prone to pronounced bone resorption in thin-wall phenotypes. Vertical bone loss was 3.5 times more severe than findings reported in the existing literature.