Geometric modeling from the medical images in the CAD system to support prosthesis design

This paper presents an individual designing prosthesis for surgical use and proposes a methodology for such design through mathematical extrapolation of data from digital images obtained via tomography of individual patient's bones. Individually tailored prosthesis designed to fit particular patient requirements as accurately as possible should result in more successful reconstruction, enable better planning before surgery and consequently fewer complications during surgery. Fast and accurate design and manufacture of personalized prosthesis for surgical use in bone replacement or reconstruction is potentially feasible through the application and integration of several different existing technologies, which are each at different stages of maturity. Initial case study experiments have been undertaken to validate the research concepts by making dimensional comparisons between a bone and a virtual model produced using the proposed methodology and a future research directions are discussed.

The human micro-vascular enclothelial cells in vitro interaction with atomic-nitrogen-doped diamond-like carbon thin films

This paper reports the initial response of atomic nitrogen doped diamond like carbon (DLC) to endothelial cells in vitro. The introduction of nitrogen atoms/molecules to the diamond like carbon structures leads to an atomic structural change favorable to the attachment of human micro-vascular enclothelial cells. Whilst the semi-conductivity induced by nitrogen in DLC is thought to play a part, the increase in the inion-bonded N atoms and N-2 molecules in the atomic doped species (with the exclusion of the charged species) seems to contribute to the improved attachment of human microvascular endothelial cells. The increased endothelial attachment is associated with a lower work function and slightly higher water contact angle in the atomic doped films, where the heavy charged particles are excluded. The films used in the study were synthesized by the RF PECVD technique followed by post deposition doping with nitrogen, and afterwards the films were characterized by XPS, Raman spectroscopy, SIMS and Kelvin probe. The water contact angles were measured, and the counts of the adherent endothelial cells on the samples were carried out. This study is relevant and contributory to improving biocompatibility of surgical implants and prostheses.

Attacking human implants: a new generation of cybercrime

Human ICT implants, such as RFID implants, cochlear implants, cardiac pacemakers, Deep Brain Stimulation, bionic limbs connected to the nervous system, and networked cognitive prostheses, are becoming increasingly complex. With ever-growing data processing functionalities in these implants, privacy and security become vital concerns. Electronic attacks on human ICT implants can cause significant harm, both to implant subjects and to their environment. This paper explores the vulnerabilities which human implants pose to crime victimisation in light of recent technological developments, and analyses how the law can deal with emerging challenges of what may well become the next generation of cybercrime: attacks targeted at technology implanted in the human body. After a state-of-the-art description of relevant types of human implants and a discussion how these implants challenge existing perceptions of the human body, we describe how various modes of attacks, such as sniffing, hacking, data interference, and denial of service, can be committed against implants. Subsequently, we analyse how these attacks can be assessed under current substantive and procedural criminal law, drawing on examples from UK and Dutch law. The possibilities and limitations of cybercrime provisions (eg, unlawful access, system interference) and bodily integrity provisions (eg, battery, assault, causing bodily harm) to deal with human-implant attacks are analysed. Based on this assessment, the paper concludes that attacks on human implants are not only a new generation in the evolution of cybercrime, but also raise fundamental questions on how criminal law conceives of attacks. Traditional distinctions between physical and non-physical modes of attack, between human bodies and things, between exterior and interior of the body need to be re-interpreted in light of developments in human implants. As the human body and technology become increasingly intertwined, cybercrime legislation and body-integrity crime legislation will also become intertwined, posing a new puzzle that legislators and practitioners will sooner or later have to solve.

Edentulous patients' knowledge of dental hygiene and care of prostheses

Objective: The aim of this study was to analyse denture users' oral care habits with regard to the use of their prostheses. Background: Rehabilitative treatment is only successful when patients are motivated and aware of correct prosthesis use and hygiene. Materials and methods: Questionnaires were distributed to 150 complete denture users at the Federal University of Bahia School of Dentistry, the Esmeralda Natividade Health Center, the Bahian Science Development Foundation and a Salvador nursing home. The questionnaire included information on gender, age, length of prosthesis use, cleaning methods and materials, etc. The data were analysed using EpiInfo version 6 software. The chi-squared test was used for statistical analysis, with a significance level of 5%. Results: Questionnaire results showed that 78% of the subjects, with an average age of 67.3 years, had used the same complete denture for over 5 years. 64% slept with their prostheses and 44% removed them from the mouth only for cleaning. None of the patients interviewed knew anything about brushes designed specifically for complete dentures. 37.3% had a restricted diet and 44% believed that a complete denture would last for more than 10 years. Conclusion: Within the limitations of this study, it was concluded that the edentulous patients surveyed had limited awareness of prosthetic hygiene and long-term oral care despite extended periods of denture use. © 2008 The Authors.

Effects of mandibular fixed implant-supported prostheses on masticatory and swallowing functions in completely edentulous elderly individuals

Purpose: To evaluate the effect of oral rehabilitation with immediately loaded fixed implant-supported mandibular prostheses on chewing and swallowing in elderly individuals. Materials and Methods: Fifteen completely edentulous patients aged more than 60 years (10 women and rive men), wearing removable dentures in both arches, had a mandibular denture replaced by an implant-supported prosthesis. All individuals were evaluated before surgery and again 3, 6, and 18 months later with regard to mastication and swallowing conditions. Examinations entailed an interview, evaluation of tactile sensitivity of the face, and observation of food intake, masticatory type, formations of bolus, and pain during mastication. The swallowing evaluation comprised observation of clinical signs related to the oral and pharyngeal stages of swallowing, as well as the presence of oral residue. The findings of different evaluations before and 3, 6, and 18 months after the surgical-prosthetic procedure were statistically compared by analysis of variance for repeated measurements at a significance level of 5%. Results: The questionnaire revealed a reduction in complaints of masticatory and swallowing disturbances, a decreased need for liquid ingestion, and reduced choking and coughing. Clinical evaluations showed improved oral function and bolus propulsion for both solid and paste-consistency foods; pain during mastication was also resolved. Conclusion: Treatment with mandibular implant-supported dentures had positive effects on the clinical aspects of mastication and swallowing in elderly individuals.

A human retrieval study of plasma-sprayed hydroxyapatite-coated plateau root form implants after 2 months to 13 years in function

Calcium phosphate-based bioactive ceramics in various physical and chemical formulations have been extensively utilized as biomaterials for bone regeneration/conduction. However, the determination of their in vivo temporal behavior from the short to long term in humans has been a challenge due to the lack of physical reference for morphologic and morphometric evaluation. The present study evaluated bone morphology and morphometry (bone-to-implant contact [BIC]) around plasma-sprayed hydroxyapatite (PSHA)-coated endosseous implants that were retrieved due to prosthetic reasons while successfully in function at the posterior region of the jaws from as early as 2 months to ~13 years after a 6-month healing period after placement. Bone morphology was evaluated by light microscopy, and BIC was determined using computer software. Irrespective of the time in vivo, lamellar bone was observed in close contact with the implant PSHA-coated surface and between plateaus. BIC ranged from ~35-95%, was highly directional, and Haversian-like osteonic morphology between plateaus was observed for most implants. The PSHA coating was present with little variation in thickness between the samples retrieved regardless of time in vivo. © 2010 by Begell House, Inc.

Effect of axial loads on implant-supported partial fixed prostheses by strain gauge analysis

Objectives: The present study used strain gauge analysis to perform an in vitro evaluation of the effect of axial loading on 3 elements of implant-supported partial fixed prostheses, varying the type of prosthetic cylinder and the loading points. Material and methods: Three internal hexagon implants were linearly embedded in a polyurethane block. Microunit abutments were connected to the implants applying a torque of 20 Ncm, and prefabricated Co-Cr cylinders and plastic prosthetic cylinders were screwed onto the abutments, which received standard patterns cast in Co-Cr alloy (n = 5). Four strain gauges (SG) were bonded onto the surface of the block tangentially to the implants, SG 01 mesially to implant 1, SG 02 and SG 03 mesially and distally to implant 2, respectively, and SG 04 distally to implant 3. Each metallic structure was screwed onto the abutments with a 10 Ncm torque and an axial load of 30 kg was applied at five predetermined points (A, B, C, D, E). The data obtained from the strain gauge analyses were analyzed statistically by RM ANOVA and Tukey's test, with a level of significance of p<0.05. Results: There was a significant difference for the loading point (p=0.0001), with point B generating the smallest microdeformation (239.49 με) and point D the highest (442.77 με). No significant difference was found for the cylinder type (p=0.748). Conclusions: It was concluded that the type of cylinder did not affect in the magnitude of microdeformation, but the axial loading location influenced this magnitude.

A new intraoral device to facilitate preparation of the guide plane for removable dental prostheses

The design of the ParalAB device facilitates transfer of the path of insertion from the diagnostic cast to the mouth quickly and efficiently.

Airway space changes after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: Three-dimensional assessment

This study focused on three-dimensional (3D) airway space changes and stability following simultaneous maxillomandibular counterclockwise rotation, mandibular advancement, and temporomandibular joint (TMJ) reconstruction with custom-made total joint prostheses (TMJ Concepts®). Cone beam computed tomography (CBCT) scans of 30 consecutive female patients with irreversibly compromised TMJs were obtained at the following intervals: T1, presurgery; T2, immediately after surgery; and T3, at least 6 months after surgery. The CBCT volumetric datasets were analysed with Dolphin Imaging ® software to evaluate surgical and postsurgical changes to oropharyngeal airway parameters. The average changes in airway surface area (SA), volume (VOL), and minimum axial area (MAA) were, 179.50 mm2, 6302.60 mm3, and 92.23 mm2, respectively, at the longest follow-up (T3 - T1) (P ≤ 0.001). Significant correlations between the amount of mandibular advancement and counterclockwise rotation of the occlusal plane and 3D airway changes were also found (P ≤ 0.01). The results of this investigation showed a significant immediate 3D airway space increase after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts total joint prostheses, which remained stable over the follow-up period. © 2013 International Association of Oral and Maxillofacial Surgeons.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts (R) total joint prostheses Part I - Skeletal and dental stability

The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total join, prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9 +/- 8.0 degrees. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9 +/- 3.5 mm at the lower incisor tips, 12.4 +/- 5.4 mm at Point B, 17.3 +/- 7.0 mm at menton, 18.4 +/- 8.5 mm at pogonion, and 11.0 +/- 5.3 mm at gonion. Vertically, the lower incisors moved upward -2.9 +/- 4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the rnaxillo-mandibular complex was a stable procedure for these patients at the longest follow-up.

Candida albicans Isolation from Buccal Mucosa of Patients with HIV Wearing Removable Dental Prostheses

Purpose: The aim of this study was to evaluate the influence of complete or partial removable dental prostheses (RDPs) on the frequency of Candida albicans isolated from the mouth and the presence of oral candidiasis in human immunodeficiency virus positive (HIV+) patients correlated with CD4 levels. Materials and Methods: One hundred ninety-three HIV+ patients were evaluated; 68 had RDPs and 125 did not. CD4 cell count was obtained after blood sampling and performed on the day of clinical examination. The material was collected from the buccal mucosa for isolation of yeasts with a sterile swab and seeded onto Sabouraud dextrose agar with chloramphenicol. C albicans strains were identified by testing germ tubes and chlamydospore formation and biochemical (zymogram, auxanogram) characteristics. The results were subjected to the Fischer exact test and chi-square tests. Results: C albicans were isolated from 45(66.17%) patients who had RDPs and 48 (38.4%) who did not (P = .0003). The presence of oral candidiasis was observed in 14 patients (7.25%), and 10 of the 14 (71.43%) were RDP users. The absence of candidiasis occurred in 121 (67.59%) nonusers and 58 (32.40%) users of RDPs (P = .0065). The mean CD4 cell count was lower in patients with oral candidiasis regardless of the use of RDPs. Conclusion: The use of RDPs was an important factor in the isolation of C albicans among HIV+ patients, and CD4 level seems to play a role in the presence of oral candidiasis. Int J Prosthodont 2012;25:127-131.

Biomechanical modelling of human knee during living activities

The knee joint is a key structure of the human locomotor system. The knowledge of how each single anatomical structure of the knee contributes to determine the physiological function of the knee, is of fundamental importance for the development of new prostheses and novel clinical, surgical, and rehabilitative procedures. In this context, a modelling approach is necessary to estimate the biomechanic function of each anatomical structure during daily living activities. The main aim of this study was to obtain a subject-specific model of the knee joint of a selected healthy subject. In particular, 3D models of the cruciate ligaments and of the tibio-femoral articular contact were proposed and developed using accurate bony geometries and kinematics reliably recorded by means of nuclear magnetic resonance and 3D video-fluoroscopy from the selected subject. Regarding the model of the cruciate ligaments, each ligament was modelled with 25 linear-elastic elements paying particular attention to the anatomical twisting of the fibres. The devised model was as subject-specific as possible. The geometrical parameters were directly estimated from the experimental measurements, whereas the only mechanical parameter of the model, the elastic modulus, had to be considered from the literature because of the invasiveness of the needed measurements. Thus, the developed model was employed for simulations of stability tests and during living activities. Physiologically meaningful results were always obtained. Nevertheless, the lack of subject-specific mechanical characterization induced to design and partially develop a novel experimental method to characterize the mechanics of the human cruciate ligaments in living healthy subjects. Moreover, using the same subject-specific data, the tibio-femoral articular interaction was modelled investigating the location of the contact point during the execution of daily motor tasks and the contact area at the full extension with and without the whole body weight of the subject. Two different approaches were implemented and their efficiency was evaluated. Thus, pros and cons of each approach were discussed in order to suggest future improvements of this methodologies. The final results of this study will contribute to produce useful methodologies for the investigation of the in-vivo function and pathology of the knee joint during the execution of daily living activities. Thus, the developed methodologies will be useful tools for the development of new prostheses, tools and procedures both in research field and in diagnostic, surgical and rehabilitative fields.

New functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb

In case of severe osteoarthritis at the knee causing pain, deformity, and loss of stability and mobility, the clinicians consider that the substitution of these surfaces by means of joint prostheses. The objectives to be pursued by this surgery are: complete pain elimination, restoration of the normal physiological mobility and joint stability, correction of all deformities and, thus, of limping. The knee surgical navigation systems have bee developed in computer-aided surgery in order to improve the surgical final outcome in total knee arthroplasty. These systems provide the surgeon with quantitative and real-time information about each surgical action, like bone cut executions and prosthesis component alignment, by mean of tracking tools rigidly fixed onto the femur and the tibia. Nevertheless, there is still a margin of error due to the incorrect surgical procedures and to the still limited number of kinematic information provided by the current systems. Particularly, patello-femoral joint kinematics is not considered in knee surgical navigation. It is also unclear and, thus, a source of misunderstanding, what the most appropriate methodology is to study the patellar motion. In addition, also the knee ligamentous apparatus is superficially considered in navigated total knee arthroplasty, without taking into account how their physiological behavior is altered by this surgery. The aim of the present research work was to provide new functional and biomechanical assessments for the improvement of the surgical navigation systems for joint replacement in the human lower limb. This was mainly realized by means of the identification and development of new techniques that allow a thorough comprehension of the functioning of the knee joint, with particular attention to the patello-femoral joint and to the main knee soft tissues. A knee surgical navigation system with active markers was used in all research activities presented in this research work. Particularly, preliminary test were performed in order to assess the system accuracy and the robustness of a number of navigation procedures. Four studies were performed in-vivo on patients requiring total knee arthroplasty and randomly implanted by means of traditional and navigated procedures in order to check for the real efficacy of the latter with respect to the former. In order to cope with assessment of patello-femoral joint kinematics in the intact and replaced knees, twenty in-vitro tests were performed by using a prototypal tracking tool also for the patella. In addition to standard anatomical and articular recommendations, original proposals for defining the patellar anatomical-based reference frame and for studying the patello-femoral joint kinematics were reported and used in these tests. These definitions were applied to two further in-vitro tests in which, for the first time, also the implant of patellar component insert was fully navigated. In addition, an original technique to analyze the main knee soft tissues by means of anatomical-based fiber mappings was also reported and used in the same tests. The preliminary instrumental tests revealed a system accuracy within the millimeter and a good inter- and intra-observer repeatability in defining all anatomical reference frames. In in-vivo studies, the general alignments of femoral and tibial prosthesis components and of the lower limb mechanical axis, as measured on radiographs, was more satisfactory, i.e. within ±3°, in those patient in which total knee arthroplasty was performed by navigated procedures. As for in-vitro tests, consistent patello-femoral joint kinematic patterns were observed over specimens throughout the knee flexion arc. Generally, the physiological intact knee patellar motion was not restored after the implant. This restoration was successfully achieved in the two further tests where all component implants, included the patellar insert, were fully navigated, i.e. by means of intra-operative assessment of also patellar component positioning and general tibio-femoral and patello-femoral joint assessment. The tests for assessing the behavior of the main knee ligaments revealed the complexity of the latter and the different functional roles played by the several sub-bundles compounding each ligament. Also in this case, total knee arthroplasty altered the physiological behavior of these knee soft tissues. These results reveal in-vitro the relevance and the feasibility of the applications of new techniques for accurate knee soft tissues monitoring, patellar tracking assessment and navigated patellar resurfacing intra-operatively in the contest of the most modern operative techniques. This present research work gives a contribution to the much controversial knowledge on the normal and replaced of knee kinematics by testing the reported new methodologies. The consistence of these results provides fundamental information for the comprehension and improvements of knee orthopedic treatments. In the future, the reported new techniques can be safely applied in-vivo and also adopted in other joint replacements.

Analysis of retrieved shoulder prostheses

In the last years the number of shoulder arthroplasties has been increasing. Simultaneously the study of their shape, size and strength and the reasons that bring to a possible early explantation have not yet been examined in detail. The research carried out directly on explants is practically nonexistent, this means a poor understanding of the mechanisms leading the patient and so the surgeon, to their removal. The analysis of the mechanisms which are the cause of instability, dislocation, broken, fracture, etc, may lead to a change in the structure or design of the shoulder prostheses and lengthen the life of the implant in situ. The idea was to analyze 22 explants through three methods in order to find roughness, corrosion and surface wear. In the first method, the humeral heads and/or the glenospheres were examined with the interferometer, a machine that through electromagnetic waves gives information about the roughness of the surfaces under examination. The output of the device was a total profile containing both roughness and information on the waves (representing the spatial waves most characteristic on the surface). The most important value is called "roughness average" and brings the average value of the peaks found in the local defects of the surfaces. It was found that 42% of the prostheses had considerable peak values in the area where the damage was caused by the implant and not only by external events, such as possibly the surgeon's hand. One of the problems of interest in the use of metallic biomaterials is their resistance to corrosion. The clinical significance of the degradation of metal implants has been the purpose of the second method; the interaction between human body and metal components is critical to understand how and why they arrive to corrosion. The percentage of damage in the joints of the prosthetic components has been calculated via high resolution photos and the software ImageJ. The 40% and 50% of the area appeared to have scratches or multiple lines due to mechanical artifacts. The third method of analysis has been made through the use of electron microscopy to quantify the wear surface in polyethylene components. Different joint movements correspond to different mechanisms of damage, which were imprinted in the parts of polyethylene examined. The most affected area was located mainly in the side edges. The results could help the manufacturers to modify the design of the prostheses and thus reduce the number of explants. It could also help surgeons in choosing the model of the prosthesis to be implanted in the patient.