Mandibular biomechanics after marginal resection: Correspondences of simulated volumetric strain and skeletal resorption.

Serious mandibular diseases such as tumor or osteonecrosis often require segmental or marginal mandibulectomy, the latter with improved outcome thanks to preserved mandibular continuity. Nevertheless, gradual osteolytic and/or osteosclerotic skeletal changes frequently indicate repetitive resections. Based on the fundamental adaptivity of bone to mechanical loads, the question arose whether resection-related anatomical alterations trigger relevant pathological skeletal adaptations. For a clinical case after mandibular box resection due to progressive osteoradionecrosis (ORN), routine biomechanical loading was simulated by finite element method, respecting pathology-related anatomy, tissue properties, and biting capacity. By 3D-visualization of the mandible's pathological development from follow-up-CT's over four years, remarkable correspondences of skeletal resorptions and increased unphysiological strain were revealed. Higher unphysiological load was correlated with more serious and earlier skeletal alterations. Three months post-operatively, serious buccal destruction at the distal resection corner occurred in correspondence with dominant tensile strain. At the resection, elevated strain caused by reduced alveolar height corresponded to skeletal compromise, observed 8-9 months post-operatively. ORN-related lesions, diagnosed before resection, entailed unphysiological strain coinciding with local skeletal alterations. Simulations with "healthy" instead of pathological tissue coefficients induced quantitative improvements of 25-33%, but without fundamental change. These results suggest a decisive contribution of resection-related biomechanical skeletal adaptations to this patient's mandibular decline with hemimandibulectomy about 2.5 years after the first resection. However, mechanical stress concentrations in sharp angles as the distal resection corner and reduced stability due to decreased alveolar height generally bear the danger of pathological biomechanics and severe skeletal adaptations for patients after mandibular box resection.

Mandibular fossa morphology during therapy with a fixed functional orthodontic appliance : A magnetic resonance imaging study.

OBJECTIVE: During therapy of distoclusion entailing a rigid, fixed orthodontic appliance, the mandibular fossa and condyle are ideally remodeled, while dentoalveolar effects occur through adaptive mechanisms. Adaptive processes, especially in the fossa region, have not been adequately investigated. Our magnetic resonance imaging (MRI) investigation aimed to assess the effects of therapy with a functional mandibular advancer (FMA) on mandibular fossa morphology. PATIENTS AND METHODS: We monitored via MRI the therapeutic course of 25 patients at three time points. Visual findings and metric assessments were carried out in the sagittal plane. Three-dimensional (3D) reconstructions of the joint structure of two exemplary patients were also made. RESULTS: Visual examinations of the MRI slices at the three time points revealed no changes in fossa shape in any of the 50 temporomandibular joints. Lateral comparisons showed that the morphology of the fossae of all 25 patients was identical. Metric analysis demonstrated no significant alterations in width, depth, or in their ratio, not even laterally. Nine measurements of the distances between the porion, mandibular fossa, and articular eminence revealed no significant changes in total or on the left and right sides, or intralaterally. CONCLUSION: The visual findings and metric analyses of parasagittal MRI slices did not indicate any morphological changes in the mandibular fossa or articular eminence in patients with distoclusion treated via a rigid, fixed orthodontic appliance. However, special reworking of the MRI data facilitated reconstruction of the surfaces of joint structures in 3D. This new method makes it possible to depict more accurately and noninvasively the adaptive mechanisms not ascertainable via metric methods and to assess them as 3D structures.

X-ray physics- and bone composition-based estimation of thickness characteristics from clinical mandibular radiographs.

In dentistry, clinical radiographs (also called X-ray images) reflect the intensity loss of an X-ray when being transmitted through the mandibular objects, and this loss is quantified in terms of grey values. While such images are standardly used for pathology detection by the experienced dentist, we here present a new method for getting more quantitative information out of such 2D radiographs, "extending" them into the third dimension. This "extension" requires consistent combination of X-ray physics (namely, X-ray intensity loss quantification along paths orthogonal to the panoramic clinical image and X-ray attenuation averaging for composite materials) with anatomically known upper and lower limits of vascular porosities in cortical and trabecular bone compartments. Correspondingly computed ranges of overall organ thicknesses are extremely narrow, suggesting adequate estimation of thickness characteristics from 2D radiographic panoramas used clinically, while predicted cortical and trabecular thickness ranges vary by ±8.47% and ±16.13%, respectively. The proposed method also identifies variations between thicknesses at similar anatomical locations left and right of the face's symmetry axis, and molar regions turn out to be thicker than those close to incisors. This paves the way to more detailed diagnostic activities, e.g. in combination with Finite Element simulations.

"Anatomical simulation" of the biomechanical behavior of the human mandible.

INTRODUCTION: The load-carrying behavior of the human mandible can be described using finite element simulation, enabling investigations about physiological and pathological skeletal adaption. "Anatomical simulation" implies a stepwise approximation towards the anatomical reality. METHOD: The project is structured in three steps. In Step 1, the preprocessing, the simulation model is provided. Step 2 is the numerical computation. Step 3 is dedicated to the interpretation of the results. The requirements of the preprocessing are: a) realization of the organ's individual anatomy, namely its outer shape; b) the tissue's elastic properties, thus its inner consistency; and c) the organ's mechanical loads. For physiological mandibular loading, these are due to muscles, temporomandibular joints, and tooth forces. Meanwhile, the reconstruction of the macroscopic anatomy from computed tomography data is standard. The periodontal ligament is inserted ex post using an approach developed by the authors. The bone is modeled anisotropically and inhomogeneously. By the visualization of the individual fiber course, the muscular force vectors are realized. The mandibular condyle is freely mobile in a kind of simplified joint capsule. For the realization of bite forces, several approaches are available. RESULTS: An extendible software tool is provided, enabling the user - by variable input of muscle and bite forces - to examine the individual patient's biomechanics, eg, the influence of the periodontal ligament, the condition of the temporomandibular joints, atrophic processes, or the biomechanical situation of dental implants. DISCUSSION: By stepwise approximation towards the anatomical reality, the mandibular simulation will be advanced to a valuable tool for diagnosis and prognosis.

Metal-induced streak artifact reduction using iterative reconstruction algorithms in x-ray computed tomography image of the dentoalveolar region.

OBJECTIVE: The objective of this study was to reduce metal-induced streak artifact on oral and maxillofacial x-ray computed tomography (CT) images by developing the fast statistical image reconstruction system using iterative reconstruction algorithms. STUDY DESIGN: Adjacent CT images often depict similar anatomical structures in thin slices. So, first, images were reconstructed using the same projection data of an artifact-free image. Second, images were processed by the successive iterative restoration method where projection data were generated from reconstructed image in sequence. Besides the maximum likelihood-expectation maximization algorithm, the ordered subset-expectation maximization algorithm (OS-EM) was examined. Also, small region of interest (ROI) setting and reverse processing were applied for improving performance. RESULTS: Both algorithms reduced artifacts instead of slightly decreasing gray levels. The OS-EM and small ROI reduced the processing duration without apparent detriments. Sequential and reverse processing did not show apparent effects. CONCLUSIONS: Two alternatives in iterative reconstruction methods were effective for artifact reduction. The OS-EM algorithm and small ROI setting improved the performance.

Near-real time oculodynamic MRI: a feasibility study for evaluation of diplopia in comparison with clinical testing.

OBJECTIVE: To demonstrate feasibility of near-real-time oculodynamic magnetic resonance imaging (od-MRI) in depicting extraocular muscles and correlate quantitatively the motion degree in comparison with clinical testing in patients with diplopia. METHODS: In 30 od-MRIs eye movements were tracked in the horizontal and sagittal plane using a a TrueFISP sequence with high temporal resolution. Three physicians graded the visibility of extraocular muscles by a qualitative scale. In 12 cases, the maximal monocular excursions in the horizontal and vertical direction of both eyes were measured in od-MRIs and a clinical test and correlated by the Pearson test. RESULTS: The medial and lateral rectus muscles were visible in the axial plane in 93% of the cases. The oblique, superior and inferior rectus muscles were overall only in 14% visible. Horizontal (p = 0,015) and vertical (p = 0,029) movements of the right eye and vertical movement of the left eye (p = 0,026) measured by od-MRI correlated positively to the clinical measurements. CONCLUSIONS: Od-MRI is a feasible technique. Visualization of the horizontal/vertical rectus muscles is better than for the superior/inferior oblique muscle. Od-MRI correlates well with clinical testing and may reproduce the extent of eye bulb motility and extraocular muscle structural or functional deteriorations. Key Points • Oculodynamic MRI technique helps clinicians to assess eye bulb motility disorders • MRI evaluation of eye movement provides functional information in cases of diplopia • Oculodynamic MRI reproduces excursion of extraocular muscles with good correlation with clinical testing • Dynamic MRI sequence supplements static orbital protocol for evaluation of motility disorders.

Influence of different modeling strategies for the periodontal ligament on finite element simulation results.

INTRODUCTION: The finite element method is a promising tool to investigate the material properties and the structural response of the periodontal ligament (PDL). To obtain realistic and reproducible results during finite element simulations of the PDL, suitable bio-fidelic finite element meshes of the geometry are essential. METHODS: In this study, 4 independent coworkers generated altogether 17 volume meshes (3-dimensional) based on the same high-resolution computed-tomography image data set of a tooth obtained in vivo to compare the influence of the different model generation techniques on the predicted response to loading for low orthodontic forces. RESULTS: It was shown that the thickness of the PDL has a significant effect on initial tooth mobility but only a remarkably moderate effect on the observed stress distribution in the PDL. Both the tooth and the bone can be considered effectively rigid when exploring the response of the PDL under low loads. The effect of geometric nonlinearities could be neglected for the applied force system. CONCLUSIONS: Most importantly, this study highlights the sensitivity of the finite element simulation results for accurate geometric reconstruction of the PDL.

Computer-assisted analysis of human upper arm flexion by 4D-visualization based on MRI.

PURPOSE: 4D-visualization of the human upper arm based on sequential or dynamic MRI may be useful in functional orthopedic disorders and surgical planning. A cascade of 4D-visualization approaches have been applied including deformation of the soft tissue surfaces and muscular contraction. Skeletal structures and the epifascial tissue comprising vascular structures are included in the 4D-visualization. METHODS: Sequential MRI (T2-weighted spin echo sequences) scans of a healthy volunteer's upper extremity were obtained. The skeletal, muscular, and epifascial tissues were segmented. For 4D-rendering of the elbow joint, surface models of the humerus, the ulna, and the radius, were displaced with respect to the movement. For 4D-visualization of the soft tissue, the processed MRI data were subjected to highly transparent direct volume rendering with special two-tone transfer functions designed with regard to the application, e.g., muscular inner structure or fasciae. For rendering of time dependent behavior, the visualization was continuously updated. RESULTS: Continuous deformation of muscular inner structure and fasciae, and dynamics of muscle fibers could be differentiated in 4D-visualizations of the upper extremity. Using sequential MRI scans, this work was constrained by the high sagittal slice thickness and separation. CONCLUSION: 4D-visualization of the upper extremity based on sequential MRI is feasible and provides a realistic appearance in comparison with anatomical drawings and preparations. The 4D-visualization method may be useful for detecting and monitoring muscular pathologies and lesions.

Globe restriction in a severely myopic patient visualized through oculodynamic magnetic resonance imaging (od-MRI).

Different mechanisms have been hypothesized as contributing to abduction deficit in high myopia: the size of the eye within the orbit, tightness of the medial rectus muscles, decompensation of longstanding esotropia, and inferior displacement of the lateral rectus muscle. Using oculodynamic magnetic resonance imaging, enhanced by computer-aided visualization, we demonstrate globe restriction by the medial orbital wall on abduction in a patient with high myopia.

Correspondences of hydrostatic pressure in periodontal ligament with regions of root resorption: a clinical and a finite element study of the same human teeth.

INTRODUCTION: The main objectives of this study were to generate individual finite element models of extracted human upper first premolars, and to simulate the distribution of the hydrostatic pressure in the periodontal ligament (PDL) of these models for evaluation of the risk of root resorption. METHODS: The individual extracted teeth were from a previous in vivo study that investigated root resorption after application of continuous intrusive forces. The results of experimental examination and simulations were compared on these identical tooth roots. The applied force system was 0.5N and 1.0N of intrusive force. RESULTS: The simulated results during intrusion of 0.5N showed regions near the apical thirds of the roots with hydrostatic pressure over the human capillary blood pressure. These regions correlated with the electron microscopies of previous studies performed in Brazil with the identical teeth. An increased force of 1.0N resulted in increased areas and magnitudes of the hydrostatic pressure. CONCLUSIONS: The key parameter indicating beginning root resorption used in this study was an increased value for hydrostatic pressure in the PDL.

Micromechanics-based conversion of CT data into anisotropic elasticity tensors, applied to FE simulations of a mandible.

Computer Tomographic (CT) image data have become a standard basis for structural analyses of bony organs. In this context, regression functions between stiffness components and Hounsfields units (HU) from CT, related to X-ray attenuation coefficients, are widely used for the definition of the (actually inhomogeneous and anisotropic) material behavior inside the organ. Herein, we suggest to derive the functional dependence of the fully orthotropic stiffness tensors on the Hounsfield units from the physical information contained in the X-ray attenuation coefficients: (i) Based on voxel average rules for the X-ray attenuation coefficients, we assign to each voxel the volume fraction occupied by water (marrow) and that occupied by solid bone matrix. (ii) By means of a continuum micromechanics representation for bone, which is based on voxel-invariant (species and whole bone-specific) stiffness properties of solid bone matrix and of water, we convert the aforementioned volume fractions into voxel-specific orthotropic stiffness tensor components. The micromechanics model, in combination with the average rule for X-ray attenuation coefficients, predicts a quasi-linear relationship between axial Young's modulus and HU, and highly nonlinear relationships for both circumferential and radial Young's moduli as well as for the shear moduli in all principal material directions. Corresponding whole-organ Finite Element (FE) analyses of a partially edentulous human mandible characterized by atrophy of the alveolar ridge show that volumetric strain concentrations/peaks within the organ are decreased when considering material anisotropy, and increased when considering material inhomogeneity.

Er:YAG laser osteotomy based on refined computer-assisted presurgical planning: first clinical experience in oral surgery.

OBJECTIVE: This case report was aimed at primary clinical experience concerning surgical extraction of a displaced tooth with the help of the Er:YAG laser based on refined computer-assisted presurgical planning. METHODS: The case refers to the extraction of a displaced maxillary canine in a female patient. For the osteotomy, a pulsed Er:YAG laser was applied with pulse energy of 500 mJ, pulse duration of 250 microsec and pulse frequency of 12 Hz. The fiber tip (1000 microm) was kept with a 1-2 mm distance to the bone surface. Refined presurgical computer-assisted planning was performed with regard to minimization of bone loss, especially for the sake of preservation of the alveolar ridge. Based on a detailed three-dimensional (3D) reconstruction of the patient's anatomy, dynamical simulations of a buccal and a palatinal variant of access osteotomy were provided. Additionally, a volumetric profile of bone tissue quality based on Hounsfield values was generated. RESULTS: By means of the 3D reconstruction and the tissue quality profile, both bone thickness and quality was evaluated as superior in the palatinal rather than in the vestibular part. Therefore, a classical buccal access window was chosen. The laser osteotomy allowed an exact cut geometry without any thermal damage and merely minimal bone loss. CONCLUSION: The enhanced possibilities by laser osteotomy allowed for full exploitation of presurgical planning. As regards the actual case, computer-assisted planning was of benefit for an appropriate choice of access osteotomy by enabling evaluation of the consistency of the bony structures.

Topography and morphology of the mandibular condyle during fixed functional orthopedic treatment --a magnetic resonance imaging study.

BACKGROUND AND AIM: Fixed functional orthopedic appliances used in 6 to 9 month-long treatments to correct distoclusion keep the mandible permanently in the therapeutically-desired protruded position. The principal aim of this approach is to achieve an increase in length of the lower jaw by stimulating mandibular growth. Ideally, adaptive mechanisms in adolescents and young adults result in condylar remodeling. Alternatively, however, therapeutically-undesirable alterations in the condyle position within the articular fossa may also occur. Thus the aim of this magnetic resonance imaging (MRI) study was twofold: 1) to verify the effects that the treatment with a fixed functional orthopedic appliance used to correct distoclusion has on the topographic relationship of mandibular condyle and glenoid fossa, and 2) to analyze morphologic changes in the condyle. PATIENTS AND METHODS: Treatment progress in 20 patients was monitored by MRI at four defined points in time. Visual inspection and metric analysis were performed in three planes (axial, frontal, parasagittal) shown on the MRIs. 3D-reconstruction of the condyle surfaces based on the MRI data sets at hand was done in selected cases. RESULTS: Upon assuming the therapeutically-desired position, the condyles were caudally and ventrally displaced from their centric position within the fossa. At the end of treatment, they had returned to their original position. When assessed laterally, statistical analysis revealed no significant differences between the joints on the right and left sides. Neither the anterior nor posterior joint space among all 40 joints exhibited significant changes in width compared to the baseline findings. Visual inspection in the axial, frontal, and sagittal planes revealed changes in the exterior form of 31 of the 40 condyles analyzed. On the whole, while morphologic changes were observed in all three planes, they were most marked in the axial plane. Metric analysis of the 2D-MRIs, on the other hand, revealed no significant changes in width, depth, or height in the plane in question. This is why we reconstructed the condyle structure three-dimensionally on a trial basis. For purposes of analysis, we super imposed the reconstructions of the condyle surfaces at the various control points on each other. By processing the data in this manner, an alternative approach for evaluating morphologic changes was created. CONCLUSIONS AND PROSPECTS: In patients treated with a rigid, fixed functional orthopedic appliance (FMA) for skeletal Class II malocclusion, both joints returned to a physiologic condyle-fossa relationship post-treatment. The improved occlusion was not achieved at the price of unphysiologic repositioning in the temporomandibular joint. Visual inspection suggested that morphologic changes in the condyle may have occurred as treatment progressed, but this was not confirmed by 2D metric analysis. However, by means of 3D-reconstruction of the condylar surfaces and their superposition, detailed visualization of adaptive mechanisms and their non-invasive evaluation in 3D may become feasible in clinical routine.