Patient doses in ct, dental cone beam ct and projection radiography in Finland, with emphasis on paediatric patients

Diagnostic radiology represents the largest man-made contribution to population radiation doses in Europe. To be able to keep the diagnostic benefit versus radiation risk ratio as high as possible, it is important to understand the quantitative relationship between the patient radiation dose and the various factors which affect the dose, such as the scan parameters, scan mode, and patient size. Paediatric patients have a higher probability for late radiation effects, since longer life expectancy is combined with the higher radiation sensitivity of the developing organs. The experience with particular paediatric examinations may be very limited and paediatric acquisition protocols may not be optimised. The purpose of this thesis was to enhance and compare different dosimetric protocols, to promote the establishment of the paediatric diagnostic reference levels (DRLs), and to provide new data on patient doses for optimisation purposes in computed tomography (with new applications for dental imaging) and in paediatric radiography. Large variations in radiation exposure in paediatric skull, sinus, chest, pelvic and abdominal radiography examinations were discovered in patient dose surveys. There were variations between different hospitals and examination rooms, between different sized patients, and between imaging techniques; emphasising the need for harmonisation of the examination protocols. For computed tomography, a correction coefficient, which takes individual patient size into account in patient dosimetry, was created. The presented patient size correction method can be used for both adult and paediatric purposes. Dental cone beam CT scanners provided adequate image quality for dentomaxillofacial examinations while delivering considerably smaller effective doses to patient compared to the multi slice CT. However, large dose differences between cone beam CT scanners were not explained by differences in image quality, which indicated the lack of optimisation. For paediatric radiography, a graphical method was created for setting the diagnostic reference levels in chest examinations, and the DRLs were given as a function of patient projection thickness. Paediatric DRLs were also given for sinus radiography. The detailed information about the patient data, exposure parameters and procedures provided tools for reducing the patient doses in paediatric radiography. The mean tissue doses presented for paediatric radiography enabled future risk assessments to be done. The calculated effective doses can be used for comparing different diagnostic procedures, as well as for comparing the use of similar technologies and procedures in different hospitals and countries.

Metabolomic and proteomic analysis of breast cancer patient samples suggests that glutamate and 12-HETE in combination with CA15-3 may be useful biomarkers reflecting tumour burden

Evaluation of protein and metabolite expression patterns in blood using mass spectrometry and high-throughput antibody-based screening platforms has potential for the discovery of new biomarkers for managing breast cancer patient treatment. Previously identified blood-based breast cancer biomarkers, including cancer antigen 15.3 (CA15-3) are useful in combination with imaging (computed tomography scans, magnetic resonance imaging, X-rays) and physical examination for monitoring tumour burden in advanced breast cancer patients. However, these biomarkers suffer from insufficient levels of accuracy and with new therapies available for the treatment of breast cancer, there is an urgent need for reliable, non-invasive biomarkers that measure tumour burden with high sensitivity and specificity so as to provide early warning of the need to switch to an alternative treatment. The aim of this study was to identify a biomarker signature of tumour burden using cancer and non-cancer (healthy controls/non-malignant breast disease) patient samples. Results demonstrate that combinations of three candidate biomarkers from Glutamate, 12-Hydroxyeicosatetraenoic acid, Beta-hydroxybutyrate, Factor V and Matrix metalloproteinase-1 with CA15-3, an established biomarker for breast cancer, were found to mirror tumour burden, with AUC values ranging from 0.71 to 0.98 when comparing non-malignant breast disease to the different stages of breast cancer. Further validation of these biomarker panels could potentially facilitate the management of breast cancer patients, especially to assess changes in tumour burden in combination with imaging and physical examination.

Lung structure and function studied by synchrotron radiation

A novel method for functional lung imaging was introduced by adapting the K-edge subtraction method (KES) to in vivo studies of small animals. In this method two synchrotron radiation energies, which bracket the K-edge of the contrast agent, are used for simultaneous recording of absorption-contrast images. Stable xenon gas is used as the contrast agent, and imaging is performed in projection or computed tomography (CT) mode. Subtraction of the two images yields the distribution of xenon, while removing practically all features due to other structures, and the xenon density can be calculated quantitatively. Because the images are recorded simultaneously, there are no movement artifacts in the subtraction image. Time resolution for a series of CT images is one image/s, which allows functional studies. Voxel size is 0.1mm3, which is an order better than in traditional lung imaging methods. KES imaging technique was used in studies of ventilation distribution and the effects of histamine-induced airway narrowing in healthy, mechanically ventilated, and anaesthetized rabbits. First, the effect of tidal volume on ventilation was studied, and the results show that an increase in tidal volume without an increase in minute ventilation results a proportional increase in regional ventilation. Second, spiral CT was used to quantify the airspace volumes in lungs in normal conditions and after histamine aerosol inhalation, and the results showed large patchy filling defects in peripheral lungs following histamine provocation. Third, the kinetics of proximal and distal airway response to histamine aerosol were examined, and the findings show that the distal airways react immediately to histamine and start to recover, while the reaction and the recovery in proximal airways is slower. Fourth, the fractal dimensions of lungs was studied, and it was found that the fractal dimension is higher at the apical part of the lungs compared to the basal part, indicating structural differences between apical and basal lung level. These results provide new insights to lung function and the effects of drug challenge studies. Nowadays the technique is available at synchrotron radiation facilities, but the compact synchrotron radiation sources are being developed, and in relatively near future the method may be used at hospitals.

Dental identification and aspects of medico-legal investigations of the Finnish victims of the Sumatra-Andaman earthquake on 26 December 2004

Tsunami waves of the Sumatra-Andaman earthquake on 26 December 2004 claimed approximately 230 000 lives and started the biggest identification operation in Interpol's history. The aim of this study was to resolve methods of the identification and results received. The viewpoint is mainly that of forensic odontology, but also includes other means of identification and results of the medico-legal examination performed in Finland. Of the 5395 victims in Thailand, approximately 2 400 were foreigners from 36 nations including 177 Finnish nationals. Additionally, a Finnish woman perished in Sri Lanka and a severely injured man after the evacuation in a hospital. The final numbers of missing persons and dead bodies registered in the Information Management Centre in Phuket,Thailand, were 3 574 ante-mortem (AM) and 3 681 post-mortem (PM) files. The number of identifications by December 2006 was 3 271 or 89% of the victims registered. Of Finnish victims, 172 have been identified in Thailand and 163 repatriated to Finland. One adult and four children are still missing. For AM data, a list of Finnish missing persons including 178 names was published on 30 December 2004. By February 2005 all useful dental AM data were available. Five persons on the list living in Finland lacked records. Based on the AM database, for the children under age 18 years (n=60) dental identification could be established for 12 (20%). The estimated number for adults (n=112) was 96 (86%). The final identification rate, based on PM examinations in Finland, was 14 (25%) for children (n= 56) and 98 (90%) for adults (n= 109). The number of Finnish victims identified by dental methods, 112 (68%), was high compared to all examined in Thailand (43%). DNA was applied for 26 Finnish children and for 6 adults, fingerprints for 24 and 7, respectively. In 12 cases two methods were applied. Every victim (n=165) underwent in Finland a medico-legal investigation including an autopsy with sampling specimens for DNA, the toxicological and histological investigation. Digital radiographs and computed tomography were taken of the whole body to verify autopsy findings and bring out changes caused by trauma, autolysis, and sampling for DNA in Thailand. Data for identification purposes were also noted. Submersion was the cause of death for 101 of 109 adults (92.7%), and trauma for 8 (7.3%). Injuries were 33 times contributing factors for submersion and 3 times for trauma-based death. Submersion was the cause of death for 51 (92.7%) children and trauma for 4 (7.3%). Injuries were in 3 cases contributing factors in submersion and once in trauma-based death. The success of the dental identification of Finnish victims is mainly based on careful registration of dental records, and on an education program from 1999 in forensic odontology.

3D Image Reconstruction From Truncated Helical Cone Beam Projection Data - A Linear Prediction Approach

With the introduction of 2D flat-panel X-ray detectors, 3D image reconstruction using helical cone-beam tomography is fast replacing the conventional 2D reconstruction techniques. In 3D image reconstruction, the source orbit or scanning geometry should satisfy the data sufficiency or completeness condition for exact reconstruction. The helical scan geometry satisfies this condition and hence can give exact reconstruction. The theoretically exact helical cone-beam reconstruction algorithm proposed by Katsevich is a breakthrough and has attracted interest in the 3D reconstruction using helical cone-beam Computed Tomography.In many practical situations, the available projection data is incomplete. One such case is where the detector plane does not completely cover the full extent of the object being imaged in lateral direction resulting in truncated projections. This result in artifacts that mask small features near to the periphery of the ROI when reconstructed using the convolution back projection (CBP) method assuming that the projection data is complete. A number of techniques exist which deal with completion of missing data followed by the CBP reconstruction. In 2D, linear prediction (LP)extrapolation has been shown to be efficient for data completion, involving minimal assumptions on the nature of the data, producing smooth extensions of the missing projection data.In this paper, we propose to extend the LP approach for extrapolating helical cone beam truncated data. The projection on the multi row flat panel detectors has missing columns towards either ends in the lateral direction in truncated data situation. The available data from each detector row is modeled using a linear predictor. The available data is extrapolated and this completed projection data is backprojected using the Katsevich algorithm. Simulation results show the efficacy of the proposed method.

Structure and deformation correlation of closed-cell aluminium foam subject to uniaxial compression

We report the results of an experimental and numerical study conducted on a closed-cell aluminium foam that was subjected to uniaxial compression with lateral constraint. X-ray computed tomography was utilized to gain access into the three-dimensional (3-D) structure of the foam and some aspects of the deformation mechanisms. A series of advanced 3-D image analyses are conducted on the 3-D images aimed at characterizing the strain localization regions. We identify the morphological/geometrical features that are responsible for the collapse of the cells and the strain localization. A novel mathematical approach based on a Minkowski tensor analysis along with the mean intercept length technique were utilized to search for signatures of anisotropy across the foam sample and its evolution as a function of loading. Our results show that regions with higher degrees of anisotropy in the undeformed foam have a tendency to initiate the onset of cell collapse. Furthermore, we show that strain hardening occurs predominantly in regions with large cells and high anisotropy. We combine the finite element method with the tomographic images to simulate the mechanical response of the foam. We predict further deformation in regions where the foam is already deformed. Crown Copyright (C) 2012 Published by Elsevier Ltd. on behalf of Acta Materialia Inc. All rights reserved.

Cryogenically cured hydroxyapatite-gelatin nanobiocomposite for bovine serum albumin protein adsorption and release

This research paper presents the first results on the protein adsorption and release kinetics and in vitro biodegradability of cryogenically cured hydroxyapatite-gelatin based micro/macroporous scaffolds (CHAMPS). While the adsorption and release of bovine serum albumin (BSA) protein exhibits steady state behavior over an incubation period of up to 10 days, Fourier transform infrared (FT-IR) analysis importantly confirms the absence of any change in the secondary structure of BSA proteins due to interaction with the CHAMPS scaffold. The compression properties of the CHAMPS scaffold with interconnected porosity (pore size similar to 50-200 mm) is characterized by a non-linear stress-strain response with a strength close to 5 MPa and a maximum strain of up to 24%. The slow but systematic increase in weight loss over a period of 7 days as well as apatite layer formation indicates its good bioactivity. The extensive micro-computed tomography (micro-CT) analysis establishes cancellous bone-like highly interconnected and complex porous architecture of the CHAMPS scaffold. Importantly, the excellent adsorption (up to 50%) and release (up to 60% of adsorbed protein) of BSA has been uniquely attributed to the inherent porous microstructure of the CHAMPS scaffold. Overall, the present study provides an assessment of the interaction of protein with the gelatin-hydroxyapatite macroporous scaffold in vitro, as well as reporting for the first time the efficacy of such scaffolds to release 60% of BSA loaded onto the scaffold in vitro, which is significantly higher than earlier literature reports.

Early osseointegration of a strontium containing glass ceramic in a rabbit model

The most important property of a bone cement or a bone substitute in load bearing orthopaedic implants is good integration with host bone with reduced bone resorption and increased bone regeneration at the implant interface. Long term implantation of metal-based joint replacements often results in corrosion and particle release, initiating chronic inflammation leading onto osteoporosis of host bone. An alternative solution is the coating of metal implants with hydroxyapatite (HA) or bioglass or the use of bulk bioglass or HA-based composites. In the above perspective, the present study reports the in vivo biocompatibility and bone healing of the strontium (Sr)-stabilized bulk glass ceramics with the nominal composition of 4.5SiO(2)-3Al(2)O(3)-1.5P(2)O(5)-3SrO-2SrF(2) during short term implantation of up to 12 weeks in rabbit animal model. The progression of healing and bone regeneration was qualitatively and quantitatively assessed using fluorescence microscopy, histological analysis and micro-computed tomography. The overall assessment of the present study establishes that the investigated glass ceramic is biocompatible in vivo with regards to local effects after short term implantation in rabbit animal model. Excellent healing was observed, which is comparable to that seen in response to a commercially available implant of HA-based bioglass alone. (C) 2013 Elsevier Ltd. All rights reserved.

Selective Review of Proton Magnetic Resonance Spectroscopy in Schizophrenia

Magnetic Resonance Spectroscopy (MRS) offers a unique opportunity to measure brain metabolites in-vivo, and in doing so enables one to understand the brain function and cellular processes implicated in the pathophysiology of psychiatric disorders. MRS, in addition to being non-invasive, is devoid of radioactive tracers and ionizing radiation, a distinct advantage over other imaging modalities like positron emission tomography and single photon emission computed tomography. With advances in MRS technique it is now possible to quantify concentrations of relevant compounds like neurotransmitters, neuronal viability markers and pharmacological compounds. Majority of the MRS studies have examined the neurometabolites in schizophrenia, a common and debilitating psychiatric disorder. Abnormalities in N Acetyl aspartate and Glutamate are consistently reported while the reports regarding the myoinsoitol and choline are inconsistent. These abnormalities are not changed across the illness stages and despite treatment. However, multiple technical challenges have limited the widespread use of MRS in psychiatric disorders. Guidelines for uniform acquisition and preprocessing are need of the hour, which. would increase the replicability and validity of MRS measures in psychiatry. Finally long term, prospective, longitudinal studies are required in different psychiatric disorders for potential clinical applications.

DECT evaluation of noncalc fied coronary artery plaque

Purpose: Composition of the coronary artery plaque is known to have critical role in heart attack. While calcified plaque can easily be diagnosed by conventional CT, it fails to distinguish between fibrous and lipid rich plaques. In the present paper, the authors discuss the experimental techniques and obtain a numerical algorithm by which the electron density (rho(e)) and the effective atomic number (Z(eff)) can be obtained from the dual energy computed tomography (DECT) data. The idea is to use this inversion method to characterize and distinguish between the lipid and fibrous coronary artery plaques. Methods: For the purpose of calibration of the CT machine, the authors prepare aqueous samples whose calculated values of (rho(e), Z(eff)) lie in the range of (2.65 x 10(23) <= rho(e) <= 3.64 x 10(23)/cm(3)) and (6.80 <= Z(eff) <= 8.90). The authors fill the phantom with these known samples and experimentally determine HU(V-1) and HU(V-2), with V-1,V-2 = 100 and 140 kVp, for the same pixels and thus determine the coefficients of inversion that allow us to determine (rho(e), Z(eff)) from the DECT data. The HU(100) and HU(140) for the coronary artery plaque are obtained by filling the channel of the coronary artery with a viscous solution of methyl cellulose in water, containing 2% contrast. These (rho(e), Z(eff)) values of the coronary artery plaque are used for their characterization on the basis of theoretical models of atomic compositions of the plaque materials. These results are compared with histopathological report. Results: The authors find that the calibration gives Pc with an accuracy of 3.5% while Z(eff) is found within 1% of the actual value, the confidence being 95%. The HU(100) and HU(140) are found to be considerably different for the same plaque at the same position and there is a linear trend between these two HU values. It is noted that pure lipid type plaques are practically nonexistent, and microcalcification, as observed in histopathology, has to be taken into account to explain the nature of the observed (rho(e), Z(eff)) data. This also enables us to judge the composition of the plaque in terms of basic model which considers the plaque to be composed of fibres, lipids, and microcalcification. Conclusions: This simple and reliable method has the potential as an effective modality to investigate the composition of noncalcified coronary artery plaques and thus help in their characterization. In this inversion method, (rho(e), Z(eff)) of the scanned sample can be found by eliminating the effects of the CT machine and also by ensuring that the determination of the two unknowns (rho(e), Z(eff)) does not interfere with each other and the nature of the plaque can be identified in terms of a three component model. (C) 2015 American Association of Physicists in Medicine.

Strength reliability and in vitro degradation of three-dimensional powder printed strontium-substituted magnesium phosphate scaffolds

Strontium ions (Sr2+) are known to prevent osteoporosis and also encourage bone formation. Such twin requirements have motivated researchers to develop Sr-substituted biomaterials for orthopaedic applications. The present study demonstrates a new concept of developing Sr-substituted Mg-3(PO4)(2) - based biodegradable scaffolds. In particular, this work reports the fabrication, mechanical properties with an emphasis on strength reliability as well as in vitro degradation of highly biodegradable strontium-incorporated magnesium phosphate cements. These implantable scaffolds were fabricated using three-dimensional powder printing, followed by high temperature sintering and/or chemical conversion, a technique adaptable to develop patient-specific implants. A moderate combination of strength properties of 36.7 MPa (compression), 242 MPa (bending) and 10.7 MPa (tension) were measured. A reasonably modest Weibull modulus of up to 8.8 was recorded after uniaxial compression or diametral tensile tests on 3D printed scaffolds. A comparison among scaffolds with varying compositions or among sintered or chemically hardened scaffolds reveals that the strength reliability is not compromised in Sr-substituted scaffolds compared to baseline Mg-3(PO4)(2). The micro-computed tomography analysis reveals the presence of highly interconnected porous architecture in three-dimension with lognormal pore size distribution having median in the range of 17.74-26.29 mu m for the investigated scaffolds. The results of extensive in vitro ion release study revealed passive degradation with a reduced Mg2+ release and slow but sustained release of Sr2+ from strontium-substituted magnesium phosphate scaffolds. Taken together, the present study unequivocally illustrates that the newly designed Sr-substituted magnesium phosphate scaffolds with good strength reliability could be used for biomedical applications requiring consistent Sr2+-release, while the scaffold degrades in physiological medium. Statement of significance The study investigates the additive manufacturing of scaffolds based on different strontium-substituted magnesium phosphate bone cements by means of three-dimensional powder printing technique (3DPP). Magnesium phosphates were chosen due to their higher biodegradability compared to calcium phosphates, which is due to both a higher solubility as well as the absence of phase changes (to low soluble hydroxyapatite) in vivo. Since strontium ions are known to promote bone formation by stimulating osteoblast growth, we aimed to establish such a highly degradable magnesium phosphate ceramic with an enhanced bioactivity for new bone ingrowth. After post-processing, mechanical strengths of up to 36.7 MPa (compression), 24.2 MPa (bending) and 10.7 MPa (tension) could be achieved. Simultaneously, the failure reliability of those bioceramic implant materials, measured by Weibull modulus calculations, were in the range of 4.3-8.8. Passive dissolution studies in vitro proved an ion release of Mg2+ and PO43- as well as Sr2+, which is fundamental for in vivo degradation and a bone growth promoting effect. In our opinion, this work broadens the range of bioceramic bone replacement materials suitable for additive manufacturing processing. The high biodegradability of MPC ceramics together with the anticipated promoting effect on osseointegration opens up the way for a patient-specific treatment with the prospect of a fast and complete healing of bone fractures. (C) 2015 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Unimpeded permeation of water through biocidal graphene oxide sheets anchored on to 3D porous polyolefinic membranes

3D porous membranes were developed by etching one of the phases (here PEO, polyethylene oxide) from melt-mixed PE/PEO binary blends. Herein, we have systematically discussed the development of these membranes using X-ray micro-computed tomography. The 3D tomograms of the extruded strands and hot-pressed samples revealed a clear picture as to how the morphology develops and coarsens over a function of time during post-processing operations like compression molding. The coarsening of PE/PEO blends was traced using X-ray micro-computed tomography and scanning electron microscopy (SEM) of annealed blends at different times. It is now understood from X-ray micro-computed tomography that by the addition of a compatibilizer (here lightly maleated PE), a stable morphology can be visualized in 3D. In order to anchor biocidal graphene oxide sheets onto these 3D porous membranes, the PE membranes were chemically modified with acid/ethylene diamine treatment to anchor the GO sheets which were further confirmed by Fourier transform infrared spectroscopy (FTIR), X-ray photoelectron spectroscopy (XPS) and surface Raman mapping. The transport properties through the membrane clearly reveal unimpeded permeation of water which suggests that anchoring GO on to the membranes does not clog the pores. Antibacterial studies through the direct contact of bacteria with GO anchored PE membranes resulted in 99% of bacterial inactivation. The possible bacterial inactivation through physical disruption of the bacterial cell wall and/or reactive oxygen species (ROS) is discussed herein. Thus this study opens new avenues in designing polyolefin based antibacterial 3D porous membranes for water purification.

Targeted regeneration of bone in the osteoporotic human femur

We have recently developed image processing techniques for measuring the cortical thicknesses of skeletal structures in vivo, with resolution surpassing that of the underlying computed tomography system. The resulting thickness maps can be analysed across cohorts by statistical parametric mapping. Applying these methods to the proximal femurs of osteoporotic women, we discover targeted and apparently synergistic effects of pharmaceutical osteoporosis therapy and habitual mechanical load in enhancing bone thickness. © 2011 Poole et al.

O acesso aos exames de alta complexidade nos planos de saúde privados na perspectiva dos usuários

A dissertação trata do acesso aos serviços de alta complexidade, particularmente os exames diagnósticos e complementares, estudado entre usuários de planos de saúde privados que buscam atendimento e diagnóstico especializado. Desde a década de 80 o usuário do sistema público de saúde vem procurando a saúde suplementar. Contudo, afirmar que o acesso é garantido no domínio privado, através da contratação dos planos de saúde, é uma incerteza que rodeia a inspiração para esta pesquisa, que se justifica pela relevância de ações que possibilitem a melhora da qualidade regulatória dos planos de saúde, a partir do controle social de seus usuários. O objetivo geral é analisar as percepções do acesso aos exames de alta complexidade nos serviços de saúde privados entre usuários de planos de saúde. Os objetivos específicos são descrever as percepções dos usuários de planos de saúde acerca do acesso aos exames de alta complexidade; analisar as motivações dos usuários de planos de saúde privados para a realização de exames de alta complexidade através da rede privada de assistência; e analisar o nível de satisfação dos usuários de planos de saúde quanto ao acesso aos exames de alta complexidade. A metodologia é qualitativa-descritiva, onde a amostra foi de trinta usuários de planos de saúde, acima de 18 anos, selecionados no campo de estudo no ano de 2010. O cenário de estudo foi um laboratório privado de medicina diagnóstica no Rio de Janeiro. As técnicas de coleta de dados utilizadas foram formulário e entrevista individual estruturada. A análise do formulário foi realizada através de estatística descritiva, e as entrevistas através da análise de conteúdo temática-categorial. Os usuários de plano de saúde declararam que o acesso é garantido com facilidade para os exames de alta complexidade. Suas principais motivações para a realização desses exames na rede privada de assistência foram caracterizadas pela rapidez de atendimento, flexibilidade e facilidade de marcação pela internet, telefone ou pessoalmente no laboratório estudado, pronta entrega dos resultados, dificuldade e morosidade do atendimento do SUS, localização do prestador credenciado próxima de bairros residenciais ou do trabalho, resolutividade diagnóstica de imagem de excelência, possibilidade de escolha pelo usuário entre as modalidades aberta e fechada de ressonância magnética e tomografia computadorizada, além da densitometria óssea que foram facilmente acessíveis a todos os sujeitos da pesquisa. O nível de satisfação foi correspondido com a rapidez na realização dos exames em caráter eletivo e de urgência quase equiparados na escala de tempo de acordo com os usuários. Contudo, embora as notas de avaliação dos usuários quanto aos seus planos de saúde tenham sido altas, foram abordadas algumas dificuldades, tais como: prazos de validade dos pedidos médicos com datação prévia; solicitações de senhas de autorização pela operadora; burocracia nos procedimentos de agendamento; dificuldades de acesso para tratamentos como implantes, fisioterapia, RPG, pilates, home care, consultas de check up; negação de reembolsos; restrição de materiais cirúrgicos, em especial as próteses e órteses; e restrições específicas de grau para cirurgias de miopia. Conclui-se que o atendimento rápido dos exames de imagem de alto custo na amostra foi descrito como satisfatório, embora a percepção de rapidez possa variar em função do tipo de produto do plano de saúde privado contratado, com necessidade de melhoria regulatória em alguns aspectos pontuais da saúde suplementar.

Avaliação da estabilidade da cirurgia de avanço mandibular através da superposição de modelos tridimensionais

Embora a cirurgia de avanço mandibular seja considerada um procedimento altamente estável, existem algumas preocupações clínicas em relação a mudanças nos côndilos e nos segmentos proximais, que podem levar a recidiva sagital e abertura de mordida. A avaliação dos resultados da cirurgia através de ferramentas de geração e superposição de modelos virtuais tridimensionais (3D) permite a identificação e quantificação dos deslocamentos e remodelação óssea que podem ajudar a explicar as interações entre os componentes dentários, esqueléticos e de tecido mole que estão relacionados a resposta ao tratamento. Este estudo observacional prospectivo avaliou, através de tomografia computadorizada de feixe cônico (CBCT), mudanças na posição/remodelação 3D dos ramos mandibulares, côndilos e mento. Assim, exames CBCT de 27 pacientes foram adquiridos antes da cirurgia (T1), imediatamente após a cirurgia(T2), e 1 ano após a cirurgia(T3). Uma técnica automática de superposição na base do crânio foi utilizada para permitir a avaliação das mudanças ocorridas nas regiões anatômicas de interesse (RAI). Os deslocamentos foram visualizados e quantificados em mapas coloridos 3D através da ferramenta de linha de contorno (ISOLINE). Pelo teste t pareado compararam-se as mudanças entre T1-T2 e T2-T3. O coeficiente de correlação de Pearson verificou se os deslocamentos ocorridos nas RAI foram correlacionados entre si e entre os tempos de avaliação. O nível de significância foi determinado em 0,05. O avanço mandibular médio foi de 6,813,2mm em T2 e 6,363,41mm em T3 (p=0,13). Entre T2 e T3, a posição do mento variou positivamente (≥2mm) em 5 pacientes negativamente em 7. 12% dos pacientes sofreram recidivas ≥4mm. Para todas as outras RAI avaliadas, apenas a porção inferior dos ramos (lado direito - 2,342,35mm e lado esquerdo 2,972,71mm) sofreram deslocamentos médios >2mm com a cirurgia. No acompanhamento em longo prazo, esse deslocamento lateral da porção inferior dos ramos foi mantido (lado direito - 2,102,15mm, p=0,26; e lado esquerdo -2,762,80, p=0,46), bem como todos os outros deslocamentos observados (p>0,05). As mudanças na posição do mento foram correlacionadas a adaptações pós-cirúrgicas nos bordos posteriores dos ramos (esquerdo r=-0,73 e direito r=-0,68) e côndilos (esquerdo r=-0,53 e direito r=-0,46). Os deslocamentos médios sofridos pelas estruturas do lado esquerdo foram suavemente maiores do que no direito. Correlações dos deslocamentos ocorridos entre T1-T2 e T2-T3 mostraram que: os deslocamentos dos côndilos esquerdos com a cirurgia foram negativamente correlacionados às adaptações pós-cirúrgicas destes (r=-0,51); e que o deslocamento da porção superior do ramo esquerdo com a cirurgia foi correlacionado à adaptação pós-cirúrgica ocorrida nos bordos posteriores (r=0,39) e côndilos do mesmo lado (r=0,39). Pode-se concluir que: (1) os deslocamentos causados pela cirurgia foram de modo geral estáveis no acompanhamento de 1 ano, mas identificou-se uma considerável variação individual; (2) as mudanças pós-cirúrgicas na posição do mento foram correlacionadas a adaptações sofridas pelos côndilos e bordos posteriores dos ramos; e que (3) deslocamentos suavemente maiores causados pela cirurgia nas estruturas do lado esquerdo levaram a maiores adaptações pós-cirúrgicas no segmento proximal deste lado.