A novel approach for planning orthognathic surgery: the integration of dental casts into three-dimensional printed mandibular models.

A method of producing a composite model consisting of a three-dimensional printed mandible bearing plaster teeth is presented. Printed models were obtained from cone beam computed tomograms (CBCT) of dry human mandibles. The plaster casts of the teeth were obtained from impressions of the teeth of the dry mandibles. The distorted teeth of the printed models were removed and replaced by the plaster casts of the teeth using a simple transfer jig. The accuracy of the composite models obtained from six mandibles was assessed from laser scans. The scans of the dry mandibles and the composite models were superimposed and the magnitude of the discrepancies at six points on the dentition and six on the mandible were obtained. It was concluded that the errors of the method were small enough to be clinically significant. The use of the composite models is illustrated in two clinical cases.

Digital replacement of the distorted dentition acquired by cone beam computed tomography (CBCT): a pilot study.

During cone beam computed tomography (CBCT) scanning, intra-oral metallic objects may produce streak artefacts, which impair the occlusal surface of the teeth. This study aimed to determine the accuracy of replacement of the CBCT dentition with a more accurate dentition and to determine the clinical feasibility of the method. Impressions of the teeth of six cadaveric skulls with unrestored dentitions were taken and acrylic base plates constructed incorporating radiopaque registration markers. Each appliance was fitted to the skull and a CBCT performed. Impressions were taken of the dentition with the devices in situ and dental models were produced. These were CBCT-scanned and the images of the skulls and models imported into computer-aided design/computer-aided manufacturing (CAD/CAM) software and aligned on the registration markers. The occlusal surfaces of each dentition were then replaced with the occlusal image of the corresponding model. The absolute mean distance between the registration markers in the skulls and the dental models was 0.09±0.02mm, and for the dentition was 0.24±0.09mm. When the method was applied to patients, the distance between markers was 0.12±0.04mm for the maxilla and 0.16±0.02mm for the mandible. It is possible to replace the inaccurate dentition on a CBCT scan using this method and to create a composite skull which is clinically acceptable.

Validation of a new method for building a three-dimensional physical model of the skull and dentition.

We present a new method for replicating the skull and occlusal surface with an accurate physical model that could be used for planning orthognathic surgery. The investigation was made on 6 human skulls, and a polyvinyl splint was fabricated on the dental cast of the maxillary dentition in each case. A cone beam computed tomogram (CBCT) was taken of each skull and a three-dimensional replica produced. The distorted dentition (as a result of magnification errors and streak artefacts) was removed from the three-dimensional model and replaced by new plaster dentition that was fabricated using the polyvinyl splint and a transfer jig replication technique. To verify the accuracy of the method the human skulls and the three dimensional replica model, with the new plaster dentition in situ, were scanned using a laser scanner. The three-dimensional images produced were superimposed to identify the errors associated with the replacement of the distorted occlusal surface with the new plaster dentition. The overall mean error was 0.72 and SD was (0.26)mm. The accuracy of the method encouraged us to use it clinically in a case of pronounced facial asymmetry.

Evaluation of an improved orthognathic articulator system. 2. Accuracy of occlusal wafers.

The errors produced by occlusal wafers constructed on casts of the teeth mounted on a standard articulator and an improved orthognathic articulator were investigated by carrying out simulated orthognathic surgery on plastic skulls. The wafers were used to relocate the position of the maxillae of the skulls. The vertical and horizontal displacements of the maxillae were determined from measurements of the positions of markers on the skull and teeth. Comparison of the magnitudes of the actual and intended movements showed that wafers constructed on the standard articulator had systematic prediction errors of up to 5mm, but the improved orthognathic articulator showed much smaller random errors. There was a statistically significant improvement in overall accuracy in predicting maxillary Le Fort I position with the use of the improved orthognathic articulator which the authors recommend for clinical use.

Evaluation of an improved orthognathic articulator system: 1. Accuracy of cast orientation.

A systematic study was carried out using plastic model skulls to quantify the accuracy of the transfer of face bow registration to the articulator. A standard Dentatus semi-adjustable articulator system was compared to a purpose built orthognathic articulator system by measuring the maxillary occlusal plane angles of plastic model skulls and of dental casts mounted on the two different types of articulators. There was a statistically significant difference between the two systems; the orthognathic system showed small random errors, but the standard system showed systematic errors of up to 28°.

Errors in orthognathic surgery planning: the effect of inaccurate study model orientation.

The results of orthognathic surgery may differ significantly from the planned outcome using dental models. The orientation of dental models mounted on articulators using conventional face bows does not accurately replicate the orientation of the patients' teeth and jaws, but introduces a systematic error. A mathematical analysis showed that the misalignment of the maxillary model introduces errors in the perioperative wafers, which may lead to the incorrect surgical positioning of the maxilla reported in the literature. The results of the mathematical analysis were validated by image analysis of photographs of mounted maxillary models, used to simulate five orthognathic procedures. No significant difference between the experimental results and the theoretical predictions from the mathematical equations was noted. Planning for maxillary forward and upward movement produced more advancement and only 50% of maxillary impaction. Planning for maxillary forward and downward movement produced less advancement and more inferior displacement in relation to horizontal and vertical reference planes.

Mandibular elongation by automatic distraction osteogenesis: the first application in humans.

We report the case of a 65-year-old man who was the first person to have the right ramus of his mandible lengthened by 20mm by automatic continuous distraction osteogenesis. The device consists of two units: a component that is implanted into the bone, and an external component that is distant from the surgical site and mounted on a battery-driven portable syringe driver or infusion pump. A non-compressible drive cable connects the two.

Mechanical evaluation of mandibular defects reconstructed using osteogenic protein-1 (rhOP-1) in a sheep model: a critical analysis.

Osteoinductive bone morphogenetic proteins (BMPs) have been used extensively in experimental and clinical orthopaedic research. It is a natural progression for these growth regulators to be tested in the craniofacial region. The aim of this investigation was to analyse the mechanical properties of the sheep mandibles reconstructed using recombinant human osteogenic protein type 1 (rhOP-1). A unilateral 35 mm osteoperiosteal continuity defect was created at the parasymphyseal region of the mandible in six adult sheep. The animals were sacrificed 3 months after surgery and mechanical properties of the regenerated bone at the operated sides (OS) were compared to the corresponding bone at the non-operated side (NOS). The regenerated tissue at the OS were then submitted for histological and histomorphometric analysis. Although all the animals achieved complete bony union, a wide range of mechanical properties was found. The rhOP-1-induced bone achieved a mean of 36% of the strength of the bone at the NOS (P < 0.05). The mean value of the stiffness of the OS was 24% of the NOS (P < 0.05). While half of the samples of the OS had 'weak' mechanical properties (9-25% strength compared to NOS) and a low stiffness (6-18%), the rest showed relatively higher strength (47-63%) and were stiffer (35-47%). Unlike the NOS, the operated sides failed under tensile stresses and cracks initiated at the superior border of the mandible. The wide mechanical variations suggest that further basic bone biology research is needed to provide better understanding of the cellular and molecular events which take place during the process of osteoinduction.

Mechanical testing of recombinant human bone morphogenetic protein-7 regenerated bone in sheep mandibles.

A new method was developed in this study for testing excised sheep mandibles as a cantilever. The method was used to determine the strength and stiffness of sheep hemi-mandibles including a 35 mm defect bridged by regenerated bone. Recombinant human bone morphogenetic protein-7 (rhBMP-7) in a bovine collagen type-I carrier was used for the bone regeneration. Initial tests on ten intact sheep mandibles confirmed that the strength, stiffness and area beneath the load-deformation curves of the right and left hemi-mandibles were not significantly different, confirming the validity of using the contra-lateral hemi-mandible as a control side. Complete bone regeneration occurred in six hemi-mandibles treated with rhBMP, but the quality and mechanical properties of the bone were very variable. The new bone in three samples contained fibrous tissue and was weaker and less stiff than the contra-lateral side (strength, 10-20 per cent; stiffness, 6-15 per cent). The other half had better-quality bone and was significantly stiffer and stronger (p < 0.05), with strength 45-63 per cent and stiffness 35-46 per cent of the contra-lateral side. Hemi-mandibles treated with collagen alone had no regenerated bone bridge suggesting that 35 mm is a critical-size bone defect.

A new capillary viscometer for small samples of whole blood.

A new capillary viscometer is described in which a column of blood is discharged under a constant pressure, producing a variety of shear stresses during a single test. Measurement of the viscosity of Newtonian sucrose solutions showed good agreement between the viscosity determined from the new system and the expected values. The viscosity of whole blood was measured in a cone-and-plate viscometer at a wide range of shear rates and characterized using a power law model; good agreement was obtained between the capillary and rotational results at low and medium shear rates. High shear rate results could also be obtained by increasing the driving pressure. The new viscometer proved to be simple to use, utilized a small test volume and produced reliable results.

The use of artificial intelligence in the design of an intelligent cognitive orthosis for people with dementia.

Dementia often reduces a person's ability to perform activities of daily living because he or she becomes confused and cannot remember the sequence of steps to perform. The current solution is to have a caregiver continually supervise and assist the person using verbal reminders or cues. This loss of privacy and increased dependency may cause the affected person to become embarrassed and agitated. We propose that this situation might be improved by using a computerized device that monitors progress and provides the reminders needed. The COACH is a first prototype of such a device. It uses artificial intelligence to observe a user, learn from his or her actions, and issue prerecorded cues of varying detail. The device was developed using a personal computer and a video camera that unobtrusively tracked the user. Preliminary testing with subjects who simulated confused behavior as they washed their hands showed that the device was performing its functions with an efficacy of approximately 95%. More extensive clinical testing and evaluation has begun, and the results will be reported in future publications.

A new capillary viscometer for whole blood viscosimetry.

A new capillary system was developed, incorporating infrared sensors, which allowed the determination of whole blood viscosity over a wide range of shear stresses. Flow conditions were defined by the geometry of the capillary and the sample pressure head. Whole blood was considered to be a power law fluid and a modified Mooney's formula was used for the calculation of the related invariants. The new viscometer proved to be very simple in use, requiring one run, had a short measuring time and utilised a small test sample volume. However it can be used for whole blood viscosity measurements only at medium and high shear stresses.

The limits of pressure sore prevention.

Pressure sore prevalence and incidence were assessed in 275 patients who were admitted to a well-staffed internal medicine ward during a 12-month study period or who were present on day 1. Pressure sore risk was assessed by use of the Braden scale and patients scoring 16 or less were provided with intensive preventive care. During the study period 5.1% (95% confidence interval 2.7-7.8) of 275 patients had pressure sores (prevalence) and 4.4% (1.9-6.9) developed sores (incidence). None of the 239 patients who were assessed as not being at risk developed a sore. 36 patients were assessed as being at risk at some time during the study and 12 of these developed sores despite receiving high-quality preventive care. The results suggest that not all pressure sores can be prevented in severely ill patients. We believe that the 4.4% incidence of sores in this study approaches the current limit of prevention.

Investigation into the tensile properties of collagen/chondroitin-6-sulphate gels: the effect of crosslinking agents and diamines.

Artificial skin substitutes based on autologous keratinocytes are being developed for grafting onto burns patients. In order to be used successfully in the clinic, these skin substitutes need to have sufficient strength to allow ease of handling. This may be achieved by crosslinking the collagen substratum on which the cells are cultured. The influence of potential crosslinking agents on the tensile properties of acellular collagen gels has been investigated, including the glycosaminoglycan, chondroitin-6-sulphate (Ch6SO4), the water-soluble carbodiimide crosslinking agents 1-ethyl-3-(3-diaminopropyl) carbodiimide (EDAC), and 1,1-carbonyldiimidazole (CDI), and the polyamines, putrescine and diaminohexane. Values for Young's modulus, maximum load, stress, displacement and percentage strain at maximum load were generated by subjecting the samples to a tear propagation test. Incorporation of 20% Ch6SO4 into collagen gels caused a significant increase in the Young's modulus, maximum load and stress at maximum load. Crosslinking treatment with EDAC, CDI or polyamines had little further benefit, and in many cases resulted in a decrease in particular parameters. In terms of mechanical strength, the best crosslinking combination proved to be the combination of CDI and diaminohexane, with results either improved or maintained when compared with the control no treatment variants. However, previous experience suggests that the use of CDI as a crosslinking reagent may inhibit infiltration and proliferation of fibroblasts in the substratum and it may be necessary to reach a compromise to obtain the best combination of biological and mechanical properties for artificial skin substitutes.

A new ambulatory monitoring instrument of posture and mobility related activities.

Long-term ambulatory monitoring of posture and mobility related activities provides useful information about the extent of disability and the outcome of rehabilitation. The aim of this project is developing an instrument which could distinguish between a set of selected mobility-related physical activities and produce parameters characterising the subjects' activity pattern; The selected activities are lying, sitting, standing and walking. A novel activity transducer and a data logger with 1MB memory are employed in the system configuration. Analytical algorithms and program are developed. The subject's whole day activity pattern and the histogram of each activity event are successfully obtained.

Direct measurement of the optical properties of human breast skin.

The optical properties of thin tissue samples are obtained using goniometric apparatus. Direct measurements of the scattering of 633 nm light by 20-120 microns thick samples of in vitro human breast epidermis and dermis are numerically integrated to obtain values for the scattering and absorption coefficients mu s and mu a, respectively, and the anisotropy parameter g. The total attenuation coefficient mu t is obtained from transmission measurements. The Beer-Lambert law is found to be sufficiently valid for congruent to 100 microns thick samples to be used as the basis of the numerical integration. However, normalisation errors involved with the integration mean that only approximate values of mu a could be obtained. Values of congruent to 40 mm-1 are obtained for mu t and mu s, with the value of mu a estimated as 1 mm-1. The optical properties of human breast epidermis and dermis are found to be similar at 633 nm, and the two could be considered as a single layer for modelling light propagation at this wavelength. Further, the intersubject variability seen in this study suggests that a model that uses a range of values for each optical property may be more useful in a clinical situation.